 |
|
  |
Free Case Review This online review service is for people who have serious injuries that have resulted in a loss of time from work and prolonged symptoms likely to result in permanent disability. My office only handles serious injuries or death. I do not handle emotional stress injuries unless the stress is the result of a physical injury or criminal act. If you do not have a serious injury or you have an emotional stress claim that is not associated with a physical injury or criminal act, please do not use this free service. Instead, you should contact the State Information and Assistance Unit. The Information and Assistance Unit is available to answer questions. There is no charge for this service. The toll-free number for general information is 800/736-7401, or you may contact your local office at 619/525-4589. If you have difficulty completing the online questionnaire, please contact us at 800/500-8922 or 858/793-5473. Every effort will be made to respond to your review request quickly. However, due to the extraordinary demand for this service, it could take up to 5 business days for me to respond. Thank you for taking the time to complete this questionnaire. I look forward to reviewing your case. |
| FREE CASE REVIEW FORM NAME: PHONE NUMBER: EMAIL ADDRESS: STREET ADDRESS: CITY: STATE: PARTS OF BODY INJURED: DATE OF INJURY: HOW WERE YOU INJURED:
PRIOR INJURIES?
NAME OF DOCTOR: TREATMENT: (*If more than one selection hold the shift key and click on items.)
CURRENT BENEFITS: (* Hold the shift key to click on multiple items.)
AMOUNT PER WEEK OF BENEFITS: NAME OF INSURANCE COMPANY: NAME OF EMPLOYER: DATE OF HIRE: BRIEFLY DESCRIBE YOUR QUESTIONS:
|
All material © 2000 The Law Office Of Jeffrey Segal Web Site Design By...
|
