On-The-Job Injuries

Workers throughout the State of Texas are exposed to dangerous conditions in the workplace on a daily basis. As a result of these dangerous conditions, workers sometimes sustain career-ending injuries. These injuries are often caused by a machine or piece of equipment that has not been designed or lacks the proper warnings which are required by law.

If you have sustained an on-the-job injury and would like to know if there is a possible claim which you may assert to receive compensation for your injuries, then, please, fill out the following questionnaire. The information provided will be kept confidential.

First Name:
Last Name:
Number, Street & Apt.:
City:
State:
Zip:
E-Mail (required):
Day Phone:
Evening Phone:
Best time to reach you by telephone?
Fax:
Date of Injury:
Name of Business:
Number & Street:
City:
State:
Zip:
Telephone:
Name of owner, if known:
Number & Street:
City:
State:
Zip:
Telephone:
Are you currently seeing a physician?	Yes No
If so, Name:
Number & Street:
City:
State:
Zip:
Telephone:
Current amount of medical bills:
Please, describe how the injury occurred:

Return to Culpepper & Associates Home Page

Jim L. Culpepper & Associates, A Professional Corporation
Attorneys at Law
9821 Katy Freeway, Suite 110 Houston, Texas, 77024
(713) 463-6300; Fax (713) 463-6301thefirm@culpepperlaw.com