Potter, Carmine and Associates

Intake Form

Cases

The "best offer" for settlement usually isn't the best - full story...

What to do if you have been injured on the job - full story...

What to do if you've been in an accident - full story...

Please fill in as much information as possible. This will allow us to review your information before contacting you.

Personal Information:
Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Spouse Name:

Your Case:
If your case involves an accident or personal injury, what is the date of the accident?

Is this accident/injury the result of a work-related incident? Yes   No 

Work-Related Injuries:
Employer Name:
Address:
City:
State:
Zip:
Work Phone:
Are you now disabled due to your injuries? Yes   No 

Accident Information:
Briefly describe how the accident happened:

Briefly describe the injuries you sustained:

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