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$15,208,168

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$15,208,168

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What type of legal matter are you inquiring about?*

Did the accident occur at a construction site?*

Did the accident involve a commercial vehicle?*

Were you or someone else injured?*

Is this a new matter or are you an existing client?*

Before we ask a few additional questions please provide your contact information.

Name*

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Please describe how your accident occurred.*

Did the accident occur at or while working?*

Please describe your injuries.*

Head and/or Brain

Neck

Back

Body and/or Ribs

Shoulders/Arms/Hands

Legs/Knees/Ankles/Feet

Burns and/or Electric Shock

Other

Select all that apply.

Have you received medical care?*

What kind of medical care have you received?*

Surgery

Specialist doctor

Ambulance (at the accident scene)

Emergency room

Medical tests (X-rays, MRI, etc.)

Regular doctor

Urgent care

Other

Please select all that apply.

In what state did the accident occur?*

Date of the accident?*

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