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Calcutt Law Firm:

315 West Pine St.
P.O. Box 31
Florence, SC 29503.

Telephone: (843) 662-5878

Fax: (843) 662-5982

Toll Free: (800) 522-2120

 

Please use the form below to contact us and we will get back to you as soon as possible. If your claim is for a child please enter their information as well.


Name:
Name & Age if claim is for a child:
Email Address:
Street Address / P.O. Box:   
City:
State:
Home Phone:
Cell Phone:
Other Phone:
List medical problems diagnosed by doctor:   

When did you last see the doctor for these problems?:
Where did you last work?:
Date last employed:
Reason you stopped working:   

Questions pertaining to Social Security Disability or SSI claims:

If you filed an application for SSA benefits, what type of claim did you file?:   

What date did you file your application?:   
Have you been denied?:   
If denied, what is the date of your denial letter?:   
Did you file an appeal?:   
Do you have an attorney representing you in your appeal?:   
Questions pertaining to Workers' Compensation and other Accident claims:

Have you been injured at work?:   
Date of your injury:   
What part of your body did you injure?:   

Did you go to the hospital or doctor after your injury:   
Are you being represented by an attorney for your work related injury?:   
Have you recently been in an automobile accident?:   
Were you charged with being at fault?:   
What type of injury did you have?:   
Did you go to the hospital or doctor after your injury:   
Has the insurance company contacted you to settle your claim?:   
Have you been recently injured in a slip and fall or other type of accident?: