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Defective Products

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Defendant:
(who caused the harm?)

Defective Products

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

Product Name

Product Model

Manufacturer

Date Purchased

Purchase Price

If the manufacturer has attempted to resolve the problem please tell us what they have done.

Please explain what is wrong with the product.

If you are aware of any online information or user groups addressing this problem please provide the links to same.

What warranties are on the product?

The product caused injury or was found to be defective on this date:

What injuries did the product cause: Nausea

Yes No

Cuts and bruises

Yes No

Broken bones

Yes No

Headaches

Yes No

Difficulty sleeping

Yes No

Anxiety

Yes No

Difficulty breathing

Yes No

Impaired vision

Yes No

Other:

Age:

Occupation:

Has a demand for compensation been made?

Yes No

State any facts that make your case particularly difficult:

*First name:

*Last name:

*Email address:

*Confirm email address:

*Phone number(s):

*Zip/Postal Code:

Best time & way to contact you:

I would like to be interviewed by a journalist.

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