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First Name
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Last Name
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Email
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Phone
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State
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What kind of claim do you have?
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Auto Accident
Malpractice
Person Injury
Workers Comp
Slip and Fall
Wrongful Death
How were you hurt?
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Auto Accident
Big Truck Accident
Motorcycle Accident,
Bike Accident
Pedestrian
Other
Were you hospitalized or did you receive medical treatment for your injury?
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Yes
No
What is the primary type of injury?
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Neck and Back
Headaches
Broken Bones
Cuts and bruises
Other Injury
Were You At Fault?
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Yes
No
When did the accident/injury occur?
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Last 30 Days
Last 60 Days
Last 90 Days
Last 1-2 Years
Over 2 Years
Have you ever signed up with a law firm to help you with this case?
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Yes
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