(757) 455-8889 (888) 694-1671
() -
(757) 455-8889
Toggle navigation
Home
Our Firm
Why Choose Us
About Us
Practice Areas
Referrals
Staff
Careers
Our Newsletter
Practice Areas
Costs
Results
Resources
Strong Justice Videos
Free Book Downloads
Firm Newsletter
Article Library
Pain Management Glossary
Testimonials
FAQs
Workplace Injury Video FAQs
Blog
Contact Us
Contact Us
Name
*
Email
*
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Best time to reach you
morning
afternoon
evening
Date of the Injury
Date Format: MM slash DD slash YYYY
Type of case
Car Accident - Hit by truck or commercial vehicle
Car Accident - Hit by drunk driver
Car Accident - Hit while pedestrian
Car Accident - Private vehicle
Motorcycle Accident
Bicycle Accident
Hurt on the Job - Virginia (VA Workers Comp)
Hurt on the Job - North Carolina (NC Workers Comp)
Wrongful Death
- Car Accident
Wrongful Death - Other
Dog Bite
Nursing Home Injury
Other Medical Malpractice
Slip and Fall
- Retail Store
Slip and Fall - Other Location
Railroad Accident - Hurt at Work (FELA)
Railroad Accident - Hit at Crossing
Other Type of Case Not Listed
Basic Injury Description
Severe Injury - In Hospital Now
Severe Injury - Injured Person in Coma Now
Severe Injury - Injured Person was in Coma
Severe Injury - Required Overnight Hospital Stay
Skull Fracture
Fracture or Fractures of Bone
Spinal Compression Fracture
Fracture(s) of One or More Bones Requiring Surgery
Brain Injury or Suspected Brain Injury
Brain Injury - Severe
Back or Neck Injury Requiring Surgery
Paralysis of One or More Limbs
Collapsed Lung
Eye Injury - Blind in One or Both Eyes
Eye Injury - Other
Herniated Disc or Discs in Back
Numbness or Shooting Pain in One or Both Legs
Herniated Disc or Discs in Neck
Numbness or Shooting Pain in One or Both Hands
Knee Injury Requiring Surgery
Shoulder Injury Requiring Surgery
Hand, Foot, Elbow or Ankle Injury Requiring Surgery
Knee Injury
Shoulder Injury
Hand, Foot or Ankle Injury
Neck Sprain/Strain
Back Sprain/Strain
Re-Injured Old Injury
Scarring - Severe
Scarring - Face
Scarring - Other Part of Body
Severe Burns
Other Injury not listed
How old is the injured person?
Please enter a number from
1
to
100
.
Message
This iframe contains the logic required to handle Ajax powered Gravity Forms.
