Question
1
What type of accident were you involved in?
Work Related Injury
Trip and Fall
Auto
Other
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2
Did the auto accident involve a commercial vehicle?
Yes
No
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Question
3
Describe your injury:
Broken Bones / Lacerations
Soft Tissue / Whiplash / Body Pain
Catastrophic / Loss of Life
Not Injured
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4
Were you hospitalized?
Yes
No
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5
Did you or will you need surgery?
Yes
No
Maybe
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6
Did the injury occur over (2) years ago?
Yes
No
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7
Do you currently have an attorney regarding your accident?
Yes
No
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Question
8
Enter Your Name and Email
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Question
9
Enter Your Phone Number
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