Burke & Eisner Attorneys Nationwide - 1.800.838.0800 Nationwide Malpractice, Cerebral Palsy, Drug Liability and Personal Injury Law Information

First we need to know a little bit about you:
Date of the Injury
Name of Injured Person
Your Name. (If not the same)
Relationship to Injured Person
Age of Injured person
Daytime Phone Number
Night Phone Number
Address
Address
City
State
Zip
To help determine if you have a claim, we need to know some basic information about your injury.
How were you injured?
Did you spend time in the hospital to treat for these injuries?	Yes No
Do you have some permanent injury?	Yes No
Did you lose time from work or lose your job after this injury?	Yes No
What state are you in?
In what state did the injury occur?
Please provide a description of your case or question and any other information you think we need to know.
Please provide your e-mail address. This is required so that we can respond to your inquiry. If you do not provide this then you may not receive a response, unless of course you have provided your phone number above.

We use your "Instant Answer" information solely to make a preliminary decision about whether you might have a claim and whether we might be able to help you. In reviewing your information we are NOT agreeing to represent you or take your case.