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Name:
Address:
Your City:
Your State:  
  Zip Code:  
Your Cell Phone:
Home Phone (if available):
Biz phone (if available):
Email:
What kind of case do you have?
Car/Truck/Boat/Motor Vehicle Accident   Medical Malpractice   Slip and fall   Product Liability Case  
Job Related Injury   Outdoor Injury   Nursing Home Neglect Case   Wrongful death   Other  
About what date did the incident occur?   
How did the accident/incident happen?
What is the extent of the injuries?
Have you incurred any medical bills (explain)?
Has a doctor been seen?    Yes     No
Have you filed a claim yet    Yes     No
Was a police report filed?    Yes     No
Were there any witnesses?    Yes     No
Do you have insurance that covers you for this type of incident?    Yes     No    Not Sure
Do other involved parties have insurance that covers this incident?    Yes     No    Not Sure
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