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FREE Personal Injury Evaluation

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How were you hurt?

Where are you hurt?
(check all that apply)

Head Neck Shoulder Back
Arm HandKnee Leg Foot
Other (describe)

First Name:

Last Name:



(555) 555-5555

Date of accident:

Place of accident:

Did you go to the hospital?

Yes No

Did you go by ambulance?

Yes No

Did you go to the emergency room?

Yes No

Do you have the police report?

Yes No

What is the total amount of medical expenses?

Do you currently have a lawyer?

Yes No

Please be aware that in submitting this form you are not retaining any law firm. The materials contained on this web site are provided for information only and do not constitute legal advice. Contact with this web site does not establish an attorney-client relationship. The information requested in the above form are the minimum facts needed for an attorney to begin to evaluate your claim. Additional information may be needed to complete your free claim evaluation.

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Last modified: 1/19/09