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Please fill out and submit the following information to receive your free case review. All the information provided will be treated with confidentiality. If you prefer to call us, please do so at (814) 454-1500 , or with our toll free number, (866) 959-1500 . We make every effort to return calls and respond to emails within 24 hours of their receipt, except on weekends and holidays.

 

Name:

Date of Birth:

Address:

Enter Your Email Address:

Home Phone:

Other Phone:

Nature of Problem - please provide an overview of your legal matter:

If you are inquiring about a potential INJURY CASE, please provide the following additional information:

1. Date and Location of your injury incident

2. Name and address(if known) of the person(s) you believe caused your injuries.

3. Please describe your injuries/losses:

3. Please describe and medical treatment you have and/or are continuing to receive:

5. Please describe any work time missed as a result of your injuries.

6. Have you been contacted by any insurance company representatives about this? If so, please describe:

7. If you have provided this information for someone else, and are not the person who was injured, please identify yourself and your relationship to the person needing assistance.