Burn Survivor Resource Center - Burn Recovery - burn survivor chat, catastrophic injury

Burn Survivor - Resource Center

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.