Full Name:

 

Address:

 

City, State, Zip:

 

Home Phone:

 

Work Phone:

 

Fax Phone:

 

E- Mail Address:

 

How would you prefer to be contacted?

 

by phone at home by phone at work by e-mail by fax by mail  

When is the best time to contact you?

 

as soon as possible mornings afternoons evenings anytime  

What type of case is this?

 

Motor Vehicle Collision Medical Malpractice Slip and Fall Case Construction Incident Civil Rights Violation - Police Assault Civil Rights Violation - Discrimination Hair Transplantation Other . . .  

Date of the Incident?

 

City Where the Incident Occured?

 

State Where the Incident Occured?

 

Briefly describe the incident that injured you:

 

Briefly describe the injuries you received:

Who do you believe was at fault:

Are any injuries permanent?

Yes No  

Did you lose any time from work because of this?

Yes No  

Are you still out of work?

Yes No  

What type of work do you perform?

How much were your monthly earnings  ?

< $1500.00 $1501.00 - $3000.00 $3001.00 - $5000.00 $5001.00 - $7500.00 $7501.00 - $10,000.00 $10,001.00 +  

Describe any other losses you may have incurred because of this injury:

If you were married at the time of the injury, describe any losses your spouse incurred:

Have you contacted another lawyer about this injury claim?

Yes No  

Did this lawyer agree to represent you?

Yes No N/A  

Does this lawyer still represent you?

Yes No N/A  

Have you negotiated with any insurance company or anyone representing them?

Yes No N/A  

Are negotiations still going on?

Yes No N/A  

List any additional questions you need answered regarding this claim:

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Please check each to indicate your agreement.

 Yes - I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.

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