
	New York personal injury lawyers handling personal injury, medical malpractice, wrongful death, car accident, truck accident, brain injury and other personal injury claims. Free consultations online or call us toll free: (888) 423-4477.

New York Personal Injury Lawyers

Providing Personal Injury Lawyers in New York State

Airplane Crashes
Asbestos
Birth Injuries
Brain Injury Lawyers
Car Accidents
Construction Site Deaths
Defective Drugs
Dog Bite / Dog Attack
Head & Brain Injuries
Medical Malpractice Lawyers
Motorcycle Accidents
Nursing Home Abuse
Personal Injury
Plane Accident Deaths
Plane Accident Lawyers
Premises Liability
Product Liability
Psychiatric Malpractice
ReNu Contact Lens Alert
Sexual Assault
Spine Injuries
SSI/SSDI
TBI
Truck Accidents
Workplace Injuries
Wrongful Death

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Title:
First Name:	*
Middle Name:
Last Name:	*
Home Phone:	*
Cell Phone:
Work Phone:
Email Address:
Address:	*
City:	*
State, Zip:	* *
What is the best way to reach you? Please provide the best place, time and method for contacting you.

Injured Person Information:

Date of Birth / Age: (ex. mm/dd/yyyy or 54)
Were you injured?	Yes No
If not, who are you inquiring on behalf of?

If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?

Is the person deceased?

Yes No

If deceased, what is the cause of death
as stated on the death certificate:

Date of Death: (ex. mm/dd/yyyy)
Was an autopsy performed?	Yes No
If not deceased, does the injury prevent you or the victim from working?	Yes No

If yes, when did you/victim stop working?
What is the approximate lost wages due to the injury?

Accident / Injury Information:

Date of Injury:	*
City where injury occured:	*
State where injury occured:	*

Please briefly explain the incident that caused the brain/head injury:
Who do you believe was at fault in causing the injury, and what do you believe they did wrong?
Describe the injuries in detail:

Do you believe the injuries are permanent?

Yes No

Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:

Please explain the full extent of the victims injuries:

Comments / Additional Information
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understanding the facts of your case?

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