Who was the person injured?

Who was the person injured?*

Me

Someone else

Name*

First Name Last Name

Your Name*

First Name Last Name

Name of Person Injured*

First Name Last Name

Their relationship to you:*

Tell us the best way to reach you.

Your best contact phone number:*

Your email address:*

Your mailing address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Where did the injury occur?

State:*

City:

(if rural area, nearest big city)

More specifics if available:

What type of product caused the injury?

What type of product caused the injury?*

(FYI – 400 character limit)

Please describe the injury:

(FYI - 400 character limit)

Please be as specific as you can.

When did the injury occur (earliest possible date)?

Year

Month

Day

I’m not sure of the month and/or day, but the season was:

Summer

Fall

Winter

Spring

Other relevant information you want to provide us:

(FYI – 400 character limit)

If for some reason you don’t hear from us within 1 business day, please call us directly at 888-775-0000. Thank you again.

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