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Practice Areas in Chinese
Insurance Bad Faith
Product Liability
Wrongful Death
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Submit Abuse Form
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Home
About
Practice Areas
Practice Areas in Chinese
Insurance Bad Faith
Product Liability
Wrongful Death
Brain Injury
Bicycle Accidents
Motorcycle Accidents
Truck Accidents
Taxi/Uber/Lyft Accidents
Food Poisoning
Government Liability
Construction Site Accidents
Premises Liability
Results
Media
Contact
Submit Abuse Form
Submit Personal Injury Form
Fee
Personal Injury Submission Form
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Your submission will be kept confidential
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Indicates required field
Your Name
*
First
Last
Injured Person's Name
*
First
Last
Phone
*
Email
*
Injured Person's Date of Birth
*
mm/dd/year
Injured Person's Job Title
*
Perpetrator's Name
*
First
Last
Date of Incident(s)
*
Incident(s) Reported to the Police?
*
Yes
No
If Reported, Date of Reporting
*
mm/dd/year
Photographs of Injuries Available?
*
Yes
No
Injured Person's Employer's Name
*
Perpetrator's Relationship to the Injured
*
If the Injured Missed Work, How Many Days?
*
If Reported to the Police, Who Reported It?
*
Do you have the perpetrator's insurance information?
*
Yes
No
Describe Incident(s)
*
Is the Injured Currently Receiving Medical Treatment?
*
Yes
No
Describe the Injuries (Types of Injury, Portion(s) of the Body Affected, Type(s) of Pain Suffered, Current Treatment)
*
List All Current Medical Treatment
*
Disclaimer: By submitting this form, I understand that it does not establish an attorney-client relationship.
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