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The Bernstein Approach
 

Defective Product

Step 2 of 3

Please tell us more about the injured person:

Injured person's first name: required field
Injured person's last name: required field
Address:
City:
State:
Zip:
Area code & phone number:
 - -
  Home Work Mobile
Age:
Gender: Male Female
______________________________

Please tell us about the accident:
Date of accident:
Accident location - City:
Accident location - State:
What product caused injury?
What was defective about the product?
How did the product defect cause injury?
______________________________

Please tell us about the injury:
Did injury require medical treatment? Yes No
Hospitalization? Yes No
If yes, how many days?
Briefly describe the injury:
Ongoing treatment? Yes No Unsure
If yes, please describe ongoing treatment:
   

required field = Required Why?

 
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