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Workers Compensation Case Evaluation

For a free case evaluation, please call our office at 1-888-890-4878 for immediate assistance. You may also submit our online case evaluation form below, and we will contact you as soon as possible.

Please provide as much information as possible when submitting the evaluation form. All information is kept strictly confidential and is used only by the Law Offices of Moskowitz & Dennis for informational purposes.

Please note that neither submission of this form nor contacting us by e-mail establishes an attorney-client relationship.

Note: fields with a (*) are required.

Personal Information
Salutation:	Mr. Mrs. Ms.
* First Name:
* Last Name:
Marital Status:	Single Married Divorced Separated Widowed
* Birth Date (mm/dd/yy):
* Age:
* Address:
* City:
* County:
* State:
* Zip Code:
* Home Phone:
Work Phone:
Cell Phone:
* E-mail Address:
Your Employer:
Employer Address:
General Information
Place of Employment:
Gross Weekly Earnings:
Address of Employment:
Are you Currently Working?:	YES NO
Date of Accident:
Time of Accident:
Name of Supervisor:
County of Accident (s):
Description of Accident:
Describe of Injuries:

IF YOU OR A LOVED ONE HAS BEEN INJURED IN AN ACCIDENT, YOU NEED THE ADVICE OF AN EXPERIENCED PERSONAL INJURY LAWYER.

CALL MOSKOWITZ & DENNIS TODAY FOR YOUR FREE CONSULTATION @ 1-888-890-HURT (4878)

E-Mail: info@injurymd.com

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CALL 24hrs TOLL FREE 888-890-HURT (4878)