| If you suspect that you or someone you know may have suffered a personal injury, you need to be informed. Please complete the following questionnaire. There is no charge for a case evaluation. When you submit the form below, practicing attorneys can review the merits of your potential case and respond directly to your inquiry. Please be as detailed as possible when filling out this form. |
New Case Inquiry Form |
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How would you like to be contacted?
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What time of day should we contact you?
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| Are you inquiring on behalf of someone else?
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| If yes: |
| What is your relationship with that person?
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| Is that person injured or deceased?
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Case Information |
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Type of case:
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Date you were injured or approximate date you first became aware of your injury
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City and State where the injury occurred:
City:
State:
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Injury Information |
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Briefly explain the incident and the injuries sustained:
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| Were you treated by a doctor or at a hospital?
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Damages Information |
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| Were you employed at the time you were injured?
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| If yes, what is your occupation?
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| Are you presently unable to work because of your injuries:
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| Have you lost any wages or time from work because of your injuries?
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| Were you married at the time of the incident?
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Legal Information |
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| Have you contacted any other attorney(s) about your potenital claim?
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| If yes, answer the following 3 questions: |
| 1. Did the attorney agree to represent you?
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| 2. Did you sign a contract?
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| 3. Are you currently represented by the attorney?
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Legal Disclaimers |
Yes
No - I agree that this information may be electronically sent to on or more attorney(s) who may then contact me directly.
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Yes
No - I agree that by submitting this information, I will not be charged for the initial response to this e-mail question. I understand that I am not forming a confidential relationship.
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Yes
No - I agree that by submitting this information, I am not forming an attorney-client relationship and I understand that the foregoing does not constitute a request for legal advice. 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 I receive in response to the above inquiry is general in nature, and is only for informational purposes. I realize that laws differ in each state and the information provided is not intended to be a substitute for professional legal advice. I understand that, when seeking lgal information, it is always important to contact a local lawyer in your area regarding any legal issues.
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Yes
No - I agree that I will not rely on any information received as legal advice. |
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