Case Evaluation – Workers Comp Counsel
Case Evaluation
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1. Were you injured at work? *
Please select an option.
2. Did you notify your employer about your injury or illness? *
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3. How long has it been since your injury or diagnosis? *
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4. Are you currently represented by a lawyer for the injury? *
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5. Would you like free legal representation from a top lawyer? *
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6. Tell us about your injury *
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7. In what state did the injury occur? *
Please select an option.
8. Please let us know the best way to contact you for your free consultation.
First Name *
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9. Please let us know the best way to contact you for your free consultation.
Last Name *
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10. Please let us know the best way to contact you for your free consultation.
Your Phone Number *
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Thank you for taking this survey.

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