Rehm Bennett Law Firm - Injury Contact Form

Rehm Bennett Moore, LLC, PC

If You Have Been Injured

If your case involves a work-related injury or sickness, please fill out this form and hit the "Submit" button at the bottom of this page.
INFORMATION SUBMITTED ON THIS FORM IS CONFIDENTIAL
We need this information to recommend qualified legal help.

What are your questions or concerns? (Providing specific questions and the information below will allow us to respond with more specific recommendations)
What is the nature of your problem?
What caused the injury or sickness?
Describe what happened?
What is the date of injury?
In what State did the injury occur or sickness begin?
Who is your employer?
Where is your employer located?
How were you hired?
Where were you at the time of your hire?
What is the current status of your injury/sickness?
What is your current work status?
What is the current status of your case?
Your name:
Address: (street, number or P.O. Box)
City:
State:
Zip code:
Email Address:
Phone Number:
Pager Number:
Best way to contact me:	How would you prefer that we contact you?
	By e-mail
	By phone
	By pager
How did you hear of us? (optional)

In Omaha: 9202 W. Dodge Road, Suite 203, Omaha, NE 68114
(402) 898-9202
In Lincoln: 3701 Union Dr., Suite 200, Lincoln, NE 68516
(402) 474-2300,
Toll Free I-800-736-5503
info@rehmbennett.com