Case Submission Form

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Full Name*
Date of Birth
Street Address*
City*
State*
Zip Code*
Country*
Email*
Home Phone*
Other Phone
Marital Status
SingleMarriedDivorcedWidowed
Name of Spouse
Occupation
Case Overview
City Injured In
State Injured In
Name & Address of Persons or Entities You Feel
Caused This Injury
Description of Injuries
Description of Treatment
Still Being Treated
YesNo
If Yes, What Kind of Treatment Are You Now Getting
And/Or Do You Anticipate in the Future?
Approximate Cost of Medical Bills
Were You Forced To Miss Work?
YesNo
Approximate Amount of Lost Wages or Benefits
Were You Contacted By An Insurance Company?
YesNo
Description of Insurance Company Contact
Are You In Contact With Another Lawyer?
YesNo
If So, Please Provide the Attorney's Name, Address
and Phone Number

Contact Information

Dayton Office

3033 Kettering Blvd.
Suite 201
Dayton, OH 45439

Toll Free: 877-623-6863
Local: 937-684-4607
Fax: 937-228-0508

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Cincinnati Office

312 Walnut St.
Suite 1600
Cincinnati, OH 45202

Toll Free: 877-623-6863
Local: 513-276-4022
Fax: 513-338-1828

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Springfield Office

20 S Limestone St. #340
Springfield, OH 45502

Toll Free: 877-623-6863 Local: 937-688-2551

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Troy Office

22 N. Short Street
Troy, OH 45373

Toll Free: 877-623-6863
Local: 937-524-0115

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By Appointment Only