Speedy Justice For Injured Workers - Better Call Su Law

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Please provide the information requested below to assist us in evaluating your workers’ compensation claim and advising you during your free confidential consultation.

Name

First Name

Last Name

Phone Number

(###)

###

####

Email Address

Date of Birth

YYYY

Date of Injury

YYYY

City Where You Reside

City Where Injury Occurred

If Injury Occurred Gradually Please State Time Period

How Injury Occurred / Body Parts Injured

Employer

Job Title / Job Duties

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