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Elevator/Escalator Case Intake Form

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The device I was injured by was an:


The incident was reported to:

I have a copy of the incident report, if one was prepared:

I have pictures of the device that caused me to be injured:


The area of the accident had video cameras:

I have, or can get the name of, a witness to the accident:

After the accident, I sought medical or hospital care:


I injured my:


The injuries have caused me to:

Additional Information:

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.