Which state do you live in?
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Florida
Georgia
Illinois
North Carolina
Ohio
Pennsylvania
Wisconsin
Other state
Do you work for the federal government (for example USPS, VA, or another federal agency)?
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Select Option
Yes
No
Did your injury happen while you were working?
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Injury on job
Yes
No
Do you already have a lawyer for this injury, or has a law firm already accepted or turned down your case?
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Has attorney
Yes
No
About when were you hurt?
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Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
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20
21
22
23
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25
26
27
28
29
30
31
Not sure
Year
2026
2025
2024
2023
Before 2023
Have you gotten, or are you trying to get, medical treatment for this injury?
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Medical treatment
Yes
No
Has this injury caused you (or should it cause you) to miss more than 5 days of work?
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Missed more than 5 days
Yes
No
Has your employer been told about the injury?
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Employer aware
Yes
No
Were you still working for that employer when you reported the injury?
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Employed when reported
Yes
No
Have you lost wages or had medical bills because of the injury?
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Lost wages or bills
Yes
No
Were you hospitalized for the injury?
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Hospitalized
Yes
No
How were you paid?
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Pay method
Paycheck (W-2)
Contractor (1099)
Cash/other
Not sure
Briefly, how did the injury happen and how serious is it?
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Long Text
Where should they reach you?
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First name
Last name
Phone
Email
ZIP code
BRD-CONSENT-SLOT
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