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PLEASE LIST DATES RELEVANT TO YOUR SITUATION. INCLUDE DATES OF AN ACCIDENT, WHEN AN INJURY OCCURRED, WHEN YOU WERE UNABLE TO WORK, ETC.

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PLEASE PROVIDE A DESCRIPTION OF YOUR LEGAL SITUATION. WHAT HAPPENED? WHAT HAS OCCURRED SINCE? DO YOU THINK SOMEONE ELSE IS 'AT FAULT' IN YOUR SITUATION? EXPLAIN:

HAVE YOU OR A LOVED ONE REQUIRED MEDICAL ATTENTION?

IF YOUR SITUATION INVOLVED AN INJURY, PLEASE DESCRIBE YOUR MEDICAL CONDITION:

PLEASE INCLUDE ANY OTHER IMPORTANT INFORMATION YOU FEEL WE SHOULD KNOW ABOUT YOUR SITUATION:

HAVE YOU SPOKEN WITH ANOTHER LAW FIRM?

PLEASE TELL US ABOUT ANY LEGAL STEPS THAT HAVE BEEN TAKEN. FOR EXAMPLE, HAVE YOU FILED FOR WORKERS' COMPENSATION BUT BEEN DENIED?, HAS AN APPEAL FOR A SOCIAL SECURITY DISABILITY CLAIM BEEN FILED? ETC.

I UNDERSTAND THAT BY SUBMITTING THIS ONLINE FORM FOR A FREE CASE EVALUATION, I AM NOT FORMING AN ATTORNEY CLIENT RELATIONSHIP. I UNDERSTAND THAT I MAY ONLY RETAIN AN ATTORNEY BY ENTERING INTO AN AGREEMENT, AND THAT I AM NOT ENTERING INTO AN AGREEMENT BY SUBMITTING THIS FORM.

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