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Defective Product (causing personal injury)

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Defendant:
(who caused the harm?)

Defective product causing personal injury

*Describe your complaint:
(briefly describe the damages you have suffered)

Have you or a loved one been injured by a defective product?

Yes No

If a loved one, what is your relationship?

What product caused the injury:

Who is the maker of the product?

Where did you purchase the product? (Store name):

When did the injury occur?

Was hospitalization required?

Yes No

Were the injuries life threatening?

Yes No

Do you have a copy of the medical records?

Yes No

Can you get a copy of the medical records?

Yes No

*First name:

*Last name:

*Email address:

*Confirm email address:

*Phone number(s):

*Zip/Postal Code:

Best time & way to contact you:

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