1. Email  
    Address:

2. Name:

3. Address:

4. City:

5. State:

6. Zip Code:  

7. Would you like an attorney to telephone you?        Yes      No

Best time to call:

Daytime Phone:

Evening Phone:

 

8. Are you above the age of 18?        Yes      No

1. Please identify the product that injured you.
                      
                   

2. When did your injury occur?     

3. Where did your injury occur?   

4. Did you purchase the product?     Yes   No
     - If yes, when did you purchase the product?    
     - If yes, who did you purchase the product from?
                          
     - If yes, do you still have the original or a copy of the receipt or contract for purchase?
                                 Yes   No   Don't Know

5. Do you still have the product in your possession?     Yes   No

6. Please describe in detail the manner in which this product caused your injury.
           
           

7. Please describe in detail the nature of your injury.
   
           

8. Did you seek medical attention for your injury?               Yes   No
     - If yes, when did you first seek medical attention?  
     - If yes, are you still treating?             Yes   No
     - If yes, how much are your medical bills to date (whether paid or not)?
                                        

9. Did you sustain property damage as a result of the incident?   Yes    No
     - If yes, please describe the type of property damage you sustained.

           
     -If yes, please estimate the monetary value of your property damage.
                                       

10. Have you lost earnings or income as a result of your injury?   Yes   No
     - If yes, please estimate your loss of earnings or income.  

11. Are there any witnesses to the incident?        Yes      No
    - If yes, please identify the name, address and telephone number of each witness.