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Construction Accident Case Intake Form

  • Step1
  • Step2
  • Step3
  • Step4

Section1

The accident happened on

I was a(n):

Other - Explain Below

Section2

Please describe how the accident happened:

The incident was reported to police:

section3

The incident was reported to my supervisor

After the accident, I sought medical or hospital care:

I injured my:

Other - Explain Below

section4

The injuries have caused me to:

Other - Explain Below

section5

Name

My email address is:

My telephone number is

I understand that the transmission of this information does not create an attorney client relationship but is, instead, a request for a free consultation with an attorney about the details of my potential case.

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