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* 1. How were you injured (describe accident/incident)?


* 2. What is the date of injury/occurrence?


* 3. Where did the incident/accident occur?


* 4. Describe your injuries.


5. Describe the medical treatment you have received and provide an estimate of your total medical bills to date.


6. If this is a workers compensation claim provide the name of your employer when you were injured?


7. If this is not a workers compensation claim identify the person(s)/business(es) that caused your injuries.


8. Do the other person or business have insurance?
Yes     No     Unknown

9. Do you have insurance that covers you for this type of accident/incident?
Yes     No     Unknown

10. Why are you seeking legal representation at this time?


* 10. Name:


* 11. E-mail Address:


* 12. Phone:


* 13. City:


* 14. State:


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An attorney/client relationship is not established by the use of this form. Your use of the form to submit a legal question constitutes your agreement that an attorney/client relationship has not been formed. Transmission of information to Penland & Munson, Attorneys | Counselors | Chartered using this form does not mean that we will accept your case, nor does it mean we will agree to represent you. We will not take any action on your behalf, nor will we agree to represent you in any matter until we have agreed, in writing, to accept your case and you have entered into a written fee agreement with the firm.

Thank you.