Your Name
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Address
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City
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State
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Zip Code
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Email Address
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Phone (xxx-xxx-xxxx)
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What type of case do you have? (Check at least one and all that apply)
What happened?
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Describe any injuries you and/or your family member suffered: (optional)
When and where did the accident, injury or death take place? (optional)
If the case involved a fatality, please tell us who died and how you are related:
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Do you have an attorney currently?
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Preferred method of initial contact:
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