The Glassman Law Firm, P.C.

231 South Bemiston Avenue
Suite 710
Clayton, Missouri 63105

Phone: 314.446.6000
Fax: 314.446.6005

Submit Your Claim

Name (or initials):
Email (confidential):
Date of your accident/injury:
Place of your injury (including county):
Person(s) or company(ies) whom your claim is potentially against:
Description of how injury occurred:
Description of your injuries:
Any permanent problems or disabilities as a result of your injury? Please describe:
Approximate cost of medical bills to date:
Type of employment - how much time has been missed:
Have you ever suffered a similar injury or condition affecting the same parts of your body that were injured in this accident? If so, please describe:
Contact number & best time to reach you:
How did you hear about us?

Disclaimer - “By submitting the above information to us, please understand that although we will treat your information as confidential, that it does not mean we yet represent you, or that we will pursue any case on your behalf. That arrangement can only be undertaken by entering into a contingent fee contract.”

Serving Missouri, St. Louis, Jefferson County, St. Charles County, St. Louis County, Franklin County, Cape Girardeau County, Butler County, St. Francois County, Warren County, Lincoln County - Madison County, Illinois, St. Clair County, IL
Website by Consultwebs.com, Inc. - Law webs for Injury Attorneys