*Name:

*Address:

*City:

*State:
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*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Who was injured?
Choose One Me Family Member Other

If "Other," please describe:

Injured person's name (if different from above):

Address:

City:

State:
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Zip:

E-mail address:

Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

When did the injury occur?

Where did the injury occur?

Was this location the injured person's
Choose One Workplace School Home Other

If "Workplace," did the injury occur as a result of employment activities?
Yes  No 

If "Other," was this a road accident?
Yes  No 

If no, did the injury occur on another's property?
Yes  No 

If yes, who owns the property?

What product caused the injury?

Manufactured by

Sold by

Owned by

Operated by

Do you know of any modifications or changes that were made to the product?
Yes  No 

If yes, who modified the product, and how was it changed?

Was the product prescribed by a health-care provider, or recommended by some other professional?
Yes  No 

If yes, what is his/her name/title/contact information?

How did the injury happen?

What were the surrounding circumstances (lighting, weather, noise, other)?

Were there witnesses to the injury?
Yes  No 

If yes, what are their names/contact information?

Were others involved or injured at the same time?
Yes  No 

If yes, what are their names/contact information?

Was there a police report?
Yes  No 

Did the injured person receive medical treatment?
Yes  No 

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
Yes  No 

Was the injured person killed as a result of the accident?
Yes  No 

If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

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