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Main Office:

85 East Main St.
Suite R
Bay Shore, NY 11706


(631) 968-9494



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Personal Injury Form


* First Name:

* Last Name:



State: Zip:

Phone Number:

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* E-Mail Address:

Who was injured?

When did the injury occur?

Where did the injury occur?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, etc.)?

Was there a police report? Yes No

Were there witnesses to the injury? Yes No

Did the injured person receive medical treatment? Yes No

Describe any lifestyle changes that were experienced or any losses
resulting from the injury (lost wages, damaged property, etc.)?


I understand that the use of this form or communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

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