Tell us about your case

Yes No
work injury
car accident
medical facility
other/not applicable

We Will Call You As Soon As Possible

Experienced, Dedicated, Trial Attorneys

When you have been injured and can't work because of your injuries, don't wait until you have been denied benefits or compensation before consulting with an attorney. If your right to benefits or compensation is being challenged, it's time to act. Call the Philadelphia disability and workers' compensation attorneys at Fenner & Boles, LLC. We can help.

1515 Market Street, #1510
Philadelphia, Pennsylvania

Two Bala Plaza, Suite 300
Bala Cynwyd, PA 19004

Toll-Free: (866) 586-9830
Phone: (215) 268-7816
Fax: (215) 827-5616

Contact Us

First Name:   
*Last Name:   
Address:   
City:   
State:   
Zip:   
Home Phone:   
Work Phone:   
*E-mail Address:   
 
What time of day would you like us to call?
  No Preference
Daytime
Evening
 

I. General Incident Information
Date you were injured.
 
City and state incident occurred.
 
Who was your employer when you were injured?
 
What was your job title when you were injured?
 
Briefly describe your job duties.
 
Briefly explain events that caused your injuries.
 
Briefly describe your injuries.
 
Are any of the injuries substantiated by diagnostic tests, and if so, which tests?
 
Did you report your injury to any supervisor or other person at the job within 120 days of the injury?
  Yes   No
If the answer to the last question was yes, when and to whom did you report your injury?
 
If the answer to the last question is no, why not?
 
Are you still under the care of a doctor?
  Yes   No
Provide the name and address of the doctor treating you for the injuries you sustained on the job.
 
Are you currently working?
  Yes   No
Are you currently receiving workers compensation benefits?
  Yes   No
Was your injury accepted as a compensable claim?
  Yes   No
Before your injury, what was your monthly gross income?
 
 

II. Legal and Insurance Issues
Have you contacted any other lawyer about your potential claim?
  Yes   No
If you contacted another lawyer, did the lawyer agree to represent you?
  Yes   No
If you contacted another lawyer, is that lawyer currently representing you?
  Yes   No
If the lawyer is not currently representing you, please tell us the circumstances under which your relationship with that lawyer terminated.
 
Have you negotiated with any insurance company or any other person in connection with this claim?
  Yes   No
If you answered yes to the previous question, are negotiations still ongoing?
  Yes   No
 

III. Legal Disclaimer
I agree that by submitting this information for evaluation, I will not be charged for the initial response. I further understand and agree that the above does not constitute a request for legal advice and that I am not forming an attorney-client relationship by submitting this information for evaluation. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.