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Jones Act Questionnaire

*Name:

Street Address:

City:

State:

Zip:

Phone:

Fax:

*Email Address:

Date and time of injury?

Location: River?
Yes  No 

Mile marker or nearest town?

On the vessel or on the tow?

Job title?

Explain how the injury occurred?

Vessel type:

What do you feel caused the injury?

Brief description of injury:

Was injury reported?
Yes  No 

Was incident report filled out?
Yes  No 

Who, if anyone, witnessed the incident?

Was a written or recorded statement given?
Yes  No 

Name of employer?

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