Pocono Summit Office HC 89 Box 105 - Route 940 Pocono Summit, PA 18346 570-839-8050 • Phone 570-839-6723 • Fax	Brodheadsville Office Merwine Commons Rt. 209 Brodheadsville, PA 18322 570-992-2109 • Phone 570-992-5090 • Fax
Contact us for a free evaluation of your injury case. Please provide as much information as possible.  Note: fields with a * are required. We will respond to your request within 24 hours.

Contact Information
*First Name:	*Last Name:
*Address 1:	Address 2:
*City:	*State:    *Zip Code:
*Home Phone:	Mobile Phone:
Work Phone:  Ext:	*E-mail Address:
What is your age?	Date of incident:
Type of Accident:  Auto Motorcycle Bus Truck Tractor Trailer Train Workers' Comp Construction Work Related Fall Down Dog Bite Perscription Error Misdiagnosis Death Social Security Pedestrian Other
If "Other", please specify:
Describe your Injuries:
Questions and Comments:
*Disclaimers:  Yes - I 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 question.