SILICOSIS INTAKE FORM

Have you worked at any of the below?:

Artificial Stone Countertop Shop/Fabrication

Stone Carving, Cutting, or Polishing

Sandblasting/Abrasive Blasting

Mining (Coal, Metal, Nonmetal)

Quarrying

Foundry

Construction (Demolition, Concrete, Masonry)

Tunneling

Ceramics and Pottery Manufacturing

Glass Manufacturing

Other

How long have you been working at the above job?

Your first name

Your middle name

Your last name

Your Birthday

Month

Day

Year

Your employer's [company] name

We will not contact your employer without your permission. Your information is confidential

Your employer's [company] address

Your work address, if different

Your position with your employer's company

If you own any legal entity, your company's name and address

Your email

Your phone

Your Home Address

Marital Status

Please list any additional jobs that you had in the last 5 years, if any

Please describe all of your other injuries, if any:

If you need a translator, please let us know your preferred language

Please list documents/evidence you have gathered so far to prove your case, if any

Have you already spoken with another attorney about this case? If so, please give their name and contact information

Are you still working with this attorney?

Has an attorney previously declined to represent you in this matter? If yes, why?

I DECLARE THAT I PERSONALLY ANSWERED THE ABOVE QUESTIONS TRUTHFULLY AND ACCURATELY TO THE BEST OF MY KNOWLEDGE. I ACKNOWLEDGE THAT FAILURE TO PROVIDE TRUTHFUL RESPONSES MAY NEGATIVELY IMPACT MY CASE

I have read and understood the Disclaimer page, Privacy Policy page, and agree with the terms.

I understand that this form serves for evaluation, is not a retainer. I understand that a formal, written, comprehensive (minimum 5 pages long) agreement should be entered to be represented by Poulsen Law P.C.. I understand that, before entering a written agreement with Poulsen Law P.C., any reliance on the information contained in this correspondence or any preceeding or follow-up communication with anyone at Poulsen Law P.C., is taken at my own risk.

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