TELL US ABOUT YOU
*Name:
*Email:
Address:
City:
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Zipcode:

Phone (Day):

Phone (Eve):
When is the
best time to reach you?

Tell us Briefly What Happened

Date of Incident:
What is the nature of your inquiry?:
Were you arrested?:
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What is the nature of the alleged crime?:

FOR PERSONAL INJURY CASES:

Were you injured?

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Describe your injuries:

Were you hospitalized? Yes No

Did you lose time from work?
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Do you currently have an attorney?
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Please provide any comments or details you'd like to share with us:
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Disclaimer  

Submitting this form to Fusco & Macaluso via this online form does not constitute an attorney / client relationship. The information that you provide to us will serve as the basis of a subsequent, detailed interview with one of our attorneys at which point critical information regarding your case, and our ability to represent you, will be discussed.

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