Taliaferro Shirooni Carran & Keys, PLLC
Attorneys At Law
Client Intake Forms

Fields marked with an * are required for the form to work.

*First Name:
*Last Name:
*E-mail Address:
Street Address:
City, State, Zip Code:
Telephone Number:

*Workers' Compensation or *Personal Injury


Workers' Compensation
Claim Information:
Where is your employer located?:
Name of employer?:
Date you were injured?:
Are you receiving workers' compensation benefits?:
YesNo
Has your employer or an insurance company denied your claim?:
YesNo
Is there a hearing scheduled which you must attend?:
YesNo
Has the insurance company told you that they want to settle your claim?
YesNo


Peronal Injury
Date of Accident / Injury?:
Place Where Accident / Injury Occurred?:
Summary of the Facts?:
 

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