Business Law | Charleston, IL | Brankey & Smith, P.C. | 217-345-6222

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Workers' Compensation | Charleston, IL | Brankey & Smith, P.C. | 217-345-6222

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For a free, no-obligation consultation with an experienced attorney regarding cases of personal injury and wrongful death, please submit the following response form. We will respect the confidentiality of your information to the fullest extent. Form submissions are relayed to us through our highly secure servers.

Please tell us who your are how we can contact you. Note: this is information is strictly confidential and will not be communicated with anyone. It is necessary only for purposes of enabling us to do a conflict of interest check prior to responding to you.

We cannot respond without being able to do our conflict check. ALL fields are required.

Case Submission Form

For a free, no-obligation consultation with an experienced attorney regarding cases of personal injury and wrongful death, please submit the following response form. We will respect the confidentiality of your information to the fullest extent. Form submissions are relayed to us through our highly secure servers.

If you prefer, you may contact us at (800) 232-1325.

Tell us who you are and how we can contact you. Note: This information is strictly confidential and will not be communicated with anyone. It is necessary only for purposes of enabling us to do a conflict of interest check prior to responding to you. We cannot respond without being able to do our conflict check. ALL fields are required.

First Name:

Last Name:

Number, Street & Apt.:

City:

State:

Zip:

Email:

Day Phone:

Night Phone:

Please provide a brief personal background of the person needing assistance. The following information is for myself:
If "No" my relationship to the following person is:

First Name:

Last Name:

Age:

Occupation:

For how long:

Current or last employed:

City and State where last employed:

Highest grade completed:

Schools/College attended:

Degrees:

Year degree granted:

Special training or experience in:

Why Do You Need Help? Please provide us with a very brief overview, in 200 words or less, describing in general the subject matter of your request:

State the date you were injured or when you first learned that you had been injured?:

What occurred?:

Where did it happen? City:

State:

County:

Who caused the harm? Please type in the names & addresses of all the wrongdoers involved:

What damages were suffered? Describe the damage you have suffered:

When is the best time to reach you by telephone?:

When the information you have provided is complete, please press the Submit button below to send it to Smith Law, Ltd. Your information will be kept strictly confidential.

If you feel more comfortable contacting us over the phone,
please give us a call as soon as possible to discuss your needs.

217-345-6222
800-232-1325

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