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Please Fax to:

Pearson & Pearson

1330 Post Oak Blvd - Suite 2900

Houston, Texas 77056

(800) 447-6443 Telephone

(713) 739-8341 Fax

Pearson & Pearson

A Professional Corporation

1330 Post Oak Blvd - Suite 2900

Houston, Texas 77056

SILICOSIS QUESTIONNAIRE

Name:_____________________________________________

Spouse: ______________________________________________

Children____________________ Ages____________

Children____________________ Ages____________

Children____________________ Ages____________

Children____________________ Ages____________

Address:_______________________________________________

Phone:( )______________________________

Social Security Number:_______ - ___________ - ____________

Date of Birth:______________________________________________________________

Place of Birth:__________________________________________

Driver's License Number or Identification Number:___________________________________

Stating the license number and issuing authority of each automobile operator, chauffeur, or commercial license which you presently possess or which you possessed in the past; and with respect to each license please state (1) the date of issuance and (2) the date of expiration:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Stating whether or not your driver's license has been suspended. If your driver's license has been suspended, please state (1) the grounds for suspension and (2) the state and agency of suspension.

List each residence at which you have lived during the past twenty (20) years giving street address, town, state, and the period of time you lived at each such address.

If you have been known by any other name, state all such former names and nicknames:

If you are currently married, please state your spouse's name, address, date of marriage, social security number, and the name and address of your spouse's employer. With respect to any and all prior spouses, if any, please state: the name and date of marriage; whether that marriage was terminated by divorce, separation, annulment, or death, and the date of such termination.

Please provide the names, date of birth, social security number and address of all your children and their birth mother.

Describe your smoking history by including dates you smoked, the amount of packs per day, and brand of cigarettes smoked.

Have you ever used any illegal drugs? If so, describe the use of such drugs.

State the name of any Union you have belonged to, the address of each Local Union and the dates you belonged to such Union.

Name Address Date

____________________ __________________________ ____________________

State the name and address of each doctor you have seen for any reason during the last 15 years and identify the approximate date you saw each doctor, and the reason for seeing each doctor. Please state whether the doctor was a union doctor, company doctor, or family doctor.

Name Address Reason Date

________________ _____________ ___________________ ______________

Describe your employment history by identifying each employer for the past 30 years, the years of employment with each employer, a brief description of the work performed, your job title and approximation of wages at each employer.

Employer Dates of

Address Employment Work/Job Title Wages

________________ _____________ ___________________ ______________

Describe in detail how much time you have missed from work, if any, since the date of the manifestation of the condition made the basis of this suit which you say is related to exposure to toxic materials, asbestos, silica, or radioactive materials and state specifically the dates involved and amount of lost wages, if any.

Identify by name and address, each co-worker that worked with you while you were exposed to silica sand or dust from working around sandblasting operations or foundry operations.

Name Address Telephone

____________________ __________________________ ____________________

For each employment location where you were exposed to silica sand or dust, identify by name and address, the plant supervisor, purchasing agent, plant health and safety manager, and/or your immediate supervisor/foreman, if known.

Name Address

__________________________ ____________________________________________

(Use more paper, if necessary).

As to each job on which you worked in a self-employed or independent contractor capacity during your lifetime, state:

Whether you were self-employed or an independent contractor. The name and address of the person or entity for whom you worked at each location. The dates and location of each and every plant or job site where you worked. The type of work or service you performed at each location and whether the work was performed in a shop or confined space, and if so, describe with specificity the ventilation of such shop or confined space.

If you have ever filed a claim for unemployment or disability benefits with the Social Security Administration, Veterans Administration or any other federal or state agency or under the terms of any insurance policy, give the name and location of the federal agency or insurance company and state the benefits received from the federal agency or insurance company.

Identify any lawsuit or worker's compensation claim you have ever filed.

Have you ever been convicted of any crime? If so, describe the crime and punishment received for any such conviction.

Do you possess any license or certification to perform any profession, trade or occupation. If so, describe the license and the date it was issued.

Have you made application for employment in the last three months? If so, please provide details on any such applications.

Describe your educational and vocations training background.

List any classes you have attended which in any way involved the handling or use or toxic materials, silica, and radioactive material and/or the handling or use of products and equipment, including safety equipment and/or procedures, which emit toxic materials and/or substances, including in your answer the dates of each such class, location of class, name of instructor or sponsor of class, and a brief description of the nature of each such class.

Please state whether you have ever attended any type of safety training and/or seminars, either provided through union participation or at the direction of an employer.

Do you recall any brand names or company names for any sand or silica products, respirator products or dust mask products?

If you have ever served in the Armed Forces of the United States, state your Rank, serial number, branch of service, dates of service, each location where you were stationed, your duties at each location, the injuries, if any, you received during your service, exposure to any and all toxicant, including but not limited to chemicals, solvents, silica, radioactive materials, or biological or chemical weapons, whether or not you claimed any disability for any injuries or conditions you received during your service, and the type of discharge you received.

Please list the name and address of each and every employer with whom you have applied for work since were diagnosed with the illness, disease or injury identified in your answers to previous interrogatories herein. With reference to these employers, please state the approximate date of application, the job sought, the hours which would be required to work, the anticipated or requested rate of pay, whether a pre-employment physical examination was required, and whether you passed said physical examination.

The undersigned certifies that all of the information given is true and correct to the best of the his/her knowledge. I/We understand that all Pearson & Pearson, P.C. ("P&P") is agreeing to at this time is to look at our case and that by completing, filling out, and faxing this form to Pearson & Pearson, P.C. no Attorney-Client relationship is yet formed.

Until P & P agrees to accept this case, and a written contract is executed by both the undersigned and P & P, P & P can and will take no action to protect our rights. We also request P & P, or any other law firm working in conjunction with P & P, to review this material and to call/contact us to discuss this matter further.

The "Legal Notices Section" of Home Page is incorporated and is agreed to.

Date: _____________________ Date: _____________________

_______________________________________ _______________________________________

Signature No. 1 Signature No. 2

"Legal Notices Section" of Home Page is incorporated and is agreed to.