Request for Consultation
How did you hear about us?
  Yellow pages Internet/Website
 

Referral
From

 
  Other  
Personal Information
  Name (injured person)
  Age
  Address
  Name (contact person)
  Telephone (work)
  Telephone (home)
  Telephone (cell)
  Confidential E-mail
  Best day and time to contact you
Type of Claim
  MVA (motor vehicle accident) LTD (Long Term Disability)
  Slip and fall
Sexual assault
  Other injury
     
  Date of accident
(denial of benefits)
  Location of accident (if applicable)
  Brief description
  Injuries:
  Were you working at the time of the accident: YES NO
  If yes, have you returned to work: YES NO N/A
 

 

Colleen L. Burn
Laurie A. Tucker
Christine M. LaCasse

Doucet McBride

85 Plymouth Street, Suite 100
Ottawa, ON K1S 3E2
T: 613-233-4474
F: 613-233-8868