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What’s your name?
Your E-mail address?
If you’re writing on behalf of someone else, what’s their name?
What phone number can we use to reach you?
Date of injury? – mm/dd/yyyy
Was the other person at fault? Yes No Don't Know
Does either person have insurance? Yes No Don't Know
Have you seen a doctor? Yes No
Were you hospitalized? Yes No
Type of Injury: — Auto Motorcycle Pedestrian vs. Vehicle Slip/trip and fall Medical malpractice Wrongful death Other type of injury Other type of case, not personal injury (divorce, etc.)
Additional Comments
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