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Connect With Personal Injury Attorneys & Lawyers Investigating Injury Lawsuit Cases & Settlement Claims…
truck driving
Truck Accident Attorneys & Lawyers. Were You or A Loved One Injured In An Accident, Crash or Wreck Involving A Truck? Connect With a Truck Accident Attorney or Lawyer.
by
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on
October 18, 2010
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Fill out this form to request a free case review by a personal injury lawyer.
were you or a loved one injured?
[Please Select]
Yes
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type of personal injury case:
[Please Select]
Car, Auto or Motor Vehicle Accident
Truck or Tractor Trailer Accident
Motorcycle Accident
Bike or Bicycle Accident
Airplane, Train, or Bus Accident
Medical Malpractice
Doctor & Hospital Negligence
Drug Injuries & Drug Side Effects
Medical Device Injury
Defective or Recalled Product Injury
Exposure To Toxic Substances
Slip, Trip or Fall
Work Injury or Job Related Accident
Other Personal Injury Claim
employer's name:
injured person's job title:
injured person's job description:
what toxic substance, chemical or toxin was the injured person exposed to:
describe the toxic exposure:
name of doctor or healthcare provider who committed medical malpractice:
name of hospital or medical facility where medical malpractice occurred:
describe the medical malpractice or negligence:
name of person, entity or company who caused the accident or injury:
date of medical malpractice or negligence:
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name of defective product:
name of product manufacturer:
describe the product defect and/or your product defect complaint:
was the product recalled:
[select]
Yes
No
Don't know
name of drug taken or prescribed:
name of drug manufacturer:
when did you start taking the drug:
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when did you stop taking the drug:
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what dosage of the drug was taken:
name of defective medical device or product:
name of medical device manufacturer:
describe the medical device defect and/or your medical device complaint:
was the medical device or product recalled?
[select]
yes
no
i don't know
describe your personal injury claim:
date of injury or accident:
Month
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state where injury or accident occurred:
[Please Select]
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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New Hampshire
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New Mexico
New York
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
name of company/person/entity that owns property where injury occurred:
type of injury or injuries suffered:
birth injury
brain damage
broken bone(s) or fracture(s)
bleeding
blindness or vision injury
burn injury
cancer
coma
concussion
contusion or bruising
chronic pain
damaged or ruptured organs
disfigurement
dislocation
hearing loss
heart attack, stroke or embolism
intellectual impairment
infection
lacerations, cuts & punctures
loss of motor function
nerve damage
paralysis, quadriplegia or paraplegia
respiratory injury
scars
scrapes, scratches & bruises
severed limb(s) or loss of body part(s)
spinal cord injury
sprains, strains or tears
wrongful death
other personal injury
describe injury or injuries suffered:
type of property where injury occurred:
residential property (e.g., house)
commercial property (e.g., business)
government property
other type of property
describe the injuries, side effects, illnesses, diseases or symptoms suffered after taking the drug:
how severe is the injury?
[Please Select]
High severity
Medium severity
Low severity
I don't know
is the injury permanent?
[Please Select]
Yes
No
I don't know
what part of body, if any, was injured:
head injury
brain injury
neck injury
shoulder injury
back injury
thorax or chest injury
abdomen injury
pelvis injury
arm or elbow injury
hand, wrist, finger or thumb injury
hip injury
leg injury or thigh injury
knee injury
eye, nose, mouth, ear or face injury
foot, ankle or toe injury
skin injury
internal organ injury
other bodily injury
other parts of body injured:
medical treatment received:
hospital or emergency room ER
ambulence or medical transport
treated by physician or doctor
prescribed drugs or medication
surgery or surgical procedure
stiches, staples or bandages
crutches and/or wheelchair
casts and/or braces
prosthetic
amputation
physical therapy PT
occupational therapy OT
chiropractic treatment
rehabilitation or rehab
x-ray, CT or CAT scan or MRI
other medical treatment
describe medical treatment received:
damages & losses suffered:
medical bills & expenses
lost wages, income or earnings
missed work
pain and suffering
loss of consortium
loss of enjoyment of life
loss of a loved one
property damage
other personal injury damages
describe any damage or loss suffered:
estimated medical bills & expenses:
estimated lost wages or loss of income:
gender of injured person:
[Please Select]
Male
Female
age of injured person:
your first name:
*
your last name:
*
name of injured person, if different, and relationship to you:
address:
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city:
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state:
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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Nevada
New Hampshire
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New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
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West Virginia
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zip / postal code:
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daytime phone number
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evening phone number
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email:
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