Workers Compensation Information and Consultation Request
We will be prompt and punctual to your appointment.
Full Name
*
First Name
Last Name
Phone
*
-
Area Code
Phone Number
E-mail
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tell us about what happened?
Please tell us as much as you can.
What is your Employers HR Contact Information?
*
Human Resources Representative
Employers HR Contact Phone Number
-
Area Code
Phone Number
Are you CURRENTLY in contact with a lawyer?
Yes
No
Yes (over 1 year ago)
In regards to THIS case only
Lawyer's Contact Information
First Name
Last Name
Lawyer Phone Number
-
Area Code
Phone Number
Have you filed an insurance claim?
Yes
No
I am waiting
In regards to THIS accident only
Insurance Company Name
Is YES to previous answer about Insurance claim
Claim # for Insurance company
Insurance Company Contact Information
First Name
Last Name
What days work best for you?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What time works best for you?
*
Morning
Afternoon
Evening
Any specific date/time?
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
I would like to be notified about other cases we are working on? Please note that we do not rent or sell your information to any third parties!
*
Yes
No
Submit
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