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Workplace Injury Evaluation

The purpose of this form is so you can tell us your story, and get the ball rolling as soon as possible. Sometimes, we find the best thing to do when beginning a legal matter is to get everything 'down on paper'. We hope this form will help you feel better, by knowing your situation will be reviewed by an attorney right away. 
 

Please know that all information is kept secure and confidential, but this form does not does not constitute or create an attorney-client relationship. If you would like further details, please review our disclaimer.

First & Last Name:
 
City:
 
State:
 
Zip Code:
 
Phone Number:
 
E-mail Address:
 
Age:
 
Date of Accident:
 
Name of Employer:
 
Address of Employer:
 
City/State where the accident occurred:
 
Briefly describe the accident:
 
Briefly describe your injuries:
 
Have you received any wage loss benefits?:
 
Have your medical bills been paid?:
 
Is there anything else we should know about your situation, right now?: