Ruby Plaintiff Form
First Name
*
Last Name
*
Phone Number
Email Address
State
*
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Attorney Name
*
Attorney Law Firm
Attorney Phone Number
*
Date of Accident
Accident Description - "How did your accident happen?"
Injury Description - "What were your injuries?"
Treatment Description - "How have you been treating for your injuries?"
Request Amount - "How much funding are you looking for?"
Referral Source - "How did you hear about us?"
*
Referral
Search Engine
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Other
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