Zip Code or City
*
I am seeking legal assistance to:
Make a claim for an injury
Defend against a claim for injury made by someone else
The claimed injury occurred on this date:
The claimed injury occurred at this location:
The claimed nature of injuries is:
Lower back pain
Upper back pain
Shoulder pain
Neck pain
Headaches
Nausea
Difficulty sleeping
Anxiety
Cuts and bruises
Broken bones
Loss of feeling in part of body
Difficulty breathing
Impaired vision
Memory loss
Was there a prior injury at the same part of the body?:
Yes
No
I don't know
If yes,on this date or over this timeperiod:
The injured party believes they have insurance that will cover this injury:
Yes
No
I don't know
Does the injured party's company have workers' compensation insurance?:
Yes
No
I don't know
There are witnesses to the injury whose names the injured party knows or will know soon:
Yes
No
The status of medical treatment is:
No treatment yet
Still receiving treatment
Stopped treatment but need to restart
Treatment completed
I don't know
If medical treatment has begun, which medical practitioners have been seen?:
Medical doctor
Surgeon
Chiropractor
Acupuncturist
Physical therapist
The medical costs to date are approximately:
$:
I don't know
There are no medical costs
$
Occupation:
The injured party missed this time from work or will likely miss this time from work because of the injury:
No work missed
This number of work days:
This number of work months:
Injured person will return to work on this date:
Injured person is still receiving treatment and is unsure when will return to work
I don't know
This number of work days:
This number of work months:
Injured person will return to work on this date:
Amount of lost work income to date is:
$:
No lost work income
I don't know
$:
Your Age:
How well do you understand your legal situation or issue? Please select the statement that best applies to your situation:
I understand my legal issue.
I have a couple of questions.
I have a couple of questions.
Gross annual income:
$25,000 or less
$25,001-$50,000
$25,001-$50,000
$75,001-$100,000
$100,001-$125,000
$125,000+
One Line Summary of your Case:
*
Describe your Case in Detail:
*
First Name
*
Last Name
*
City
*
State or Province
*
Zip / Postcode
*
Phone
*
Email
*
Contact Preferences
Release my contact infoto Attorneys
*
Yes
No
Notify me when attorneys respond by:
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Email
Text Message
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What level of experience would you like your attorneyto have?
No preference
6-15 years experience
1-5 years experience
over 16 years of experience
How Will You Pay?
Cash
Credit Card
Family
Check
Friend
I can't pay.
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