"Know your Rights, Let us Protect Them" The requested information that you provide is strictly confidential. Our office will review this information to determine the viability of a claim on your behalf. There is no charge or obligation, and submitting a form does not create an attorney / client relationship. A member of our legal team will review this information and respond the following day. You can always contact us directly at 1-888-227-4770 seven days a week. About the Injured Person: First Name : Last Name : Address : City : State : Zip: Email Address : Home Phone : Work Phone: Age : Sex : M F Date of Incident : Description of Accident : Who do you feel is responsible for your injury? Brief Description of Injury : Anything else you would like to tell?:

2827 E. Saginaw | Lansing,MI 48912 | 1-888-227-4770 Free Phone Consultation | Free Home and Hospital Visit