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If this is for a family member, please indicate your relationship to the injured party.    

Name of Injured Party:    Injured DOB: 

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This case involves an injury/accident that occurred on your job: yes
 
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Date of Accident or Injury:   Time: 
 
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An attorney from our office will contact you to discuss your case.  Please be aware that submitting this form does not create an attorney/client relationship between you and Rywant Alvarez Jones Russo & Guyton, P.A.    
    

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