Case Evaluation

* Your Name (last, first, middle)

* Address

* City

* State

* Zip Code

Phone (Home)

* Phone (Cell)

* Email

* Date of Birth

* State of Residence

* Date Of Incident

* Incident Location

New Case or Existing Case

Case Number and County

* Incident Description

Injuries Description

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(A Friend, Internet Search, Radio Advertisement, AVVO, Former Client of Burnham Injury Law, Present Client of Burnham Injury Law)

NOTICE: This office does not represent you with regard to the matters set forth in this INITIAL MATTER EVALUATION until both you and the Firm enter into a Legal Representation Agreement.

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