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Chicago Car Accident

Injured In A Motorcycle Accident? Connect With A Chicago Motorcycle Accident Lawyer or Attorney.

by admin on July 16, 2015

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Injured In A Truck Accident? Connect With A Chicago Truck Accident Lawyer or Trucking Accident Attorney.

by admin on July 15, 2015

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Injured In A Car Crash in Chicago? Connect With A Chicago Car Crash Lawyer or Attorney.

by admin on July 12, 2015

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Injured In A Car Wreck in Chicago? Connect With A Chicago Car Wreck Lawyer or Attorney.

by admin on July 11, 2015

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Fill out this form to request a free review by a personal injury lawyer.
were you or a loved one injured in a personal injury accident?*
type of personal injury accident:
employer's name:
injured person's job title:
injured person's job description:
what toxic substance, chemical or toxin was the injured person exposed to:
describe the toxic exposure:
i.e., how were you or a loved one exposed to the toxic chemicals or toxins?
name of doctor or healthcare provider who committed medical malpractice:
name of hospital or medical facility where medical malpractice occurred:
describe the medical malpractice or negligence:
(i.e. what happened? how were you injured by a doctor, hospital or other healthcare provider?)
name of person, entity or company who caused the accident or injuries:
date of medical malpractice or negligence:
MM slash DD slash YYYY
name of defective product:
name of product manufacturer:
describe the product defect and/or your product defect complaint:
(i.e., how is the product defective, unsafe or dangerous?)
was the product recalled:
name of drug taken or prescribed:

(i.e., which prescription drug, medicine, medication, Rx or pharmaceutical caused injuries?)
name of drug manufacturer:
when did you start taking the drug:
MM slash DD slash YYYY
when did you stop taking the drug:
MM slash DD slash YYYY
what dosage of the drug was taken:
name of defective medical device or product:
name of medical device manufacturer:
describe the medical device defect and/or your medical device complaint:
(i.e., how is the medical device or product defective, unsafe or dangerous?
was the medical device or product recalled?
describe the personal injury accident:
date of personal injury accident:
MM slash DD slash YYYY
state where injury or accident occurred:
city where injury or accident occurred:
name of company, person or entity that owns or controls the property upon which injured person slipped, tripped and/or fell:
type of injury or injuries suffered:
- broken bones & fractures
- spinal cord or vertebrae damage
- burns & burn injury
- severed limbs or loss of body parts
- disfigurement, scars & wounds
- lacerations, cuts & punctures
- sprains, strains or tears
- scrapes, scratches & bruises
- bleeding & blood loss
- soft tissue injuries
- dislocation & dislocated joint
- birth injuries & birth defects
- paralysis, quadriplegia or paraplegia
- loss of motor function
- concussion
- coma or unconscious
- wrongful death
- other personal injuries
describe injury or injuries suffered:
type of propery on which slip, trip and fall occurred:
- Residential property (i.e., house, apartment, etc.)
- Commericial or Business property (i.e., hotel, restaurant, etc.)
- Government
- Other type of property
describe the injuries, side effects, illnesses, diseases or symptoms suffered after taking the drug:
(i.e., what is your drug injury complaint? how were you hurt or injured?)
are the injuries, side effects, illnesses or symptoms permanent?
what part of body, if any, was injured:
- head injury & head trauma
- brain injury & brain damage
- neck injury
- shoulder injury
- back injury
- chest injury
- stomach, naval or abdomin injury
- arm and elbow injury
- hand, wrist, finger or thumb injury
- hip injury
- leg injury or knee injury
- eye, nose, mouth, ear or face injury
- foot, ankle or toe injury
- internal organ injury
other parts of body injured:
medical treatment received or required by injured person:
- hospital or emergency room ER visit
- ambulence or medical transport
- treated by physician or doctor
- prescribed drugs or medication
- surgery or surgical procedure
- stiches, staples or bandages
- crutches and/or wheelchair
- casts and/or braces
- prosthetic and/or amputation
- physical therapy PT
- occupational therapy OT
- chiropractic treatment
- rehabilitation or rehab
- x-ray, CT or CAT scan or MRI
- other medical treatment
describe medical treatment required or received by injured person:
(i.e., how did doctor, physician or hospital treat injuries?)
damages & losses suffered:
- medical bills & expenses
- disfigurement
- disability
- lost wages, income or earnings
- missed work
- pain and suffering
- emotional distress
- loss of normal life
- pecuniary loss | death of loved one
- shortened life expectancy
- caretaking expenses
- increased risk of future harm
- property damage
- other personal injury damages
describe any damage or loss suffered:
estimated medical bills & expenses:
estimated lost wages or income:
estimated property damage:
other expenses or damages:
gender of injured person:
age of injured person:
your first name:*
your last name:*
name of injured person, if different, and relationship to you:
address:*
city:*
state:*
zip / postal code:*
daytime phone number:*
evening phone number:*
email:*
terms & conditions*
- I agree to the terms & conditions
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Injured In A Motorcycle Accident? Connect With A Chicago Motorcycle Accident Lawyer or Attorney.
Injured In A Truck Accident? Connect With A Chicago Truck Accident Lawyer or Trucking Accident Attorney.
Injured In A Car Crash in Chicago? Connect With A Chicago Car Crash Lawyer or Attorney.
Injured In A Car Wreck in Chicago? Connect With A Chicago Car Wreck Lawyer or Attorney.

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