On-The-Job Injuries

Workers throughout the State of Texas are exposed to dangerous conditions in the workplace on a daily basis. As a result of these dangerous conditions, workers sometimes sustain career-ending injuries. These injuries are often caused by a machine or piece of equipment that has not been designed or lacks the proper warnings which are required by law.

 

If you have sustained an on-the-job injury and would like to know if there is a possible claim which you may assert to receive compensation for your injuries, then, please, fill out the following questionnaire. The information provided will be kept confidential.

Thank you for providing this information.
 

First Name:
Last Name:
Number, Street & Apt.:
City:
State:
Zip:
E-Mail (required):
Day Phone:
Evening Phone:
Best time to reach you by telephone?
Fax:
Date of Injury:
Name of Business:
Number & Street:
City:
State:
Zip:
Telephone:
Name of owner, if known:
Number & Street:
City:
State:
Zip:
Telephone:
Are you currently seeing a physician? Yes No
If so, Name:
Number & Street:
City:
State:
Zip:
Telephone:
Current amount of medical bills:
Please, describe how the injury occurred:

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