Thank you {Your Name (First):26.3} {Your Name (Last):26.6} for providing us with the details of your workers’ Compensation Case.
We’ll review your submission and contact you as soon as possible.

*To review, is this your correct phone number and email?
Your phone number: {Your phone number:28}
Your E-mail: {Email:27}

If it is not, please contact us as soon as possible
and provide us with the correct contact details.

Your case is time-sensitive and needs our immediate attention.

(877) 776-9558