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Have you been injured on the job?

We are anxious to help you. There are two ways you can contact us about your case. You can either call us at 1.800.556.8404 to talk to one of our client service representatives or you can fill out the on-line form below and submit it to us from this website at any time. After completing the form you may submit it by simply clicking on the I AGREE button after reading our necessary disclaimer.

  • Personal Information

  • (cell)
  • (home)
  • (work)

  • Accident Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • (city, state)
  • (optional)
  • (check all that apply)
  • Date Format: MM slash DD slash YYYY

  • Disclaimer

    WARNING: If you are a LegalShield Member you may not use this method of seeking legal assistance. You must call the 1.800 number on your membership card. If you submit a request in this manner we will not be able to process you as a LegalShield member which could result in significant delays.

    DISCLAIMER: Before you can submit your case for potential review, you must read and agree to the following: "I understand that by submitting this information to Merritt Webb, I have not created an attorney/client relationship with Merritt Webb and that Merritt Webb has no responsibility to protect my interests in this matter in any way unless and until I enter into a signed, written fee agreement with Merritt Webb. I understand that Merritt Webb has no obligation to reply to this email and are not responsible for this matter. By clicking on the I Agree button below, I hereby submit my information on this basis and certify that I have read the GENERAL Disclaimer."

GENERAL DISCLAIMER

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