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First Name
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Last Name
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Email Address
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Phone Number
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Have you or your loved one suffered an injury?
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Did the injury require medical treatment?
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When did the injury occur?
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In what state did the injury occur?*
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Alabama
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Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Ohio
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Oregon
Pennsylvania
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South Carolina
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Tennessee
Texas
Utah
Vermont
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Washington
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What are the details of the incident?
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-Select One-
Accidents involving one or more automobiles
Asbestos-related diseases/Mesothelioma
Birth injury or birth defects
Dangerous drug, medical device, or product
Denial of SSDI/SSI benefits
Denial of worker’s compensation
Denial or termination of disability benefits/coverage through a private insurer
Dog bite
Elder abuse at a nursing or assisted living facility
Injured at a private residence, a business premises or public space
Medical mistake or misdiagnosis
Military disability benefits
Slip and fall
Stockbroker fraud or misconduct
Workplace accident or accident that occurred while performing work duties
Other
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