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For a free consultation please fill out the form below:

First Name:
Last Name:
Street Address:



  Zip Code:

Home Phone:

Work Phone:

Cell Phone:



Family Member Contact Information:
If you are contacting us on behalf of the injured party, please provide your Name, Address, and Phone Number:

Are you currently represented by counsel?
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Would you like to learn more about your legal rights?
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Please provide the following injury information in the area below:
  • Date and Location of the Injury?
  • Burn Survivor's date of birth and occupation?
  • Where and how the injury occurred?
  • Witnesses to the injury?
  • Any unsafe conditions that may have caused the injury?

When were you (or the party of concern) injured?

Please select the type of burns you suffered:

What percentage of your body was burned in the accident?

If your injuries occurred at work please provide:

  • The name of the company you work for
  • A description of your job
  • A description of the site where your injury occurred

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First Name:
Last Name:
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Describe your accident:
Describe your injuries:
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