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  • Phone: 1-800-560-2139

Have you been seriously injured in an accident?

Please fill out the form below so we can better understand your case and work with you to achieve the results you are entitled to. After submitting the form below you will be contacted by our firm within 24 hours. Should you require assistance before that time, please feel free to call us at 1-800-560-2139.

Your Name (required)

Your Email

Phone

Address

City*

State

ZIP Code

Were witnesses present? YesNo

Have you seen a doctor? YesNo

Have you filed a claim? YesNo

Have you filed a police report? YesNo

Have you given a record statement?* YesNo

Did the "at-fault" party have insurance?* YesNo

How did the incident occur?

What type of injuries did you suffer?

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Please Read Before Submitting your Message: Please note that any communication with our firm through this website does not constitute or create an attorney-client relationship with our firm. By clicking “Submit,” you agree that we may review any information you transmit to us. You recognize that our review of your information, even if it is highly confidential and even if it is transmitted in a good faith effort to retain us, does not constitute or create an attorney-client relationship.