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First Name:

Last Name:

Street Address:

Suite:

City:

State:
  Zip Code:

Home Phone:

Work Phone:

Cell Phone:

Fax:

Email:

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?
Yes No

Would you like to learn more about your legal rights?
Yes No


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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If you have comments or questions regarding your legal rights, please contact us.
Burn Survivor Resource Center 1-800-669-7700.


Copyright © 2001, 2002 The Law Offices of Robert A. Brenner. All rights reserved.