Disclaimer: Submitting your question via e-mail does not create an attorney client relationship and should not be relied upon as such.

YOUR INFORMATION

First name:

Last name:
Address:

Apartment/Floor:
City:
State:
Zip code:
E-mail address:
Phone:

CLIENT INFORMATION

First name:
Last name:
Address:
Apartment/Floor:
City:
State:
Zip code:
E-mail address:
Phone:

Please detail your question here:


HELPFUL HINTS
The following list of questions will help you organize events and information related to an accident and/or incident:

FACTS OF THE MATTER
Type of case:


Date of incident:


Injuries:


What happened?:


Have you contacted another attorney?
YES    NO

If yes, who?


REFERRAL SOURCE
Television
Yellow Pages
Newspaper
Attorney
Past/present client
Other Client
Other

ADVERSE INFORMATION
Adverse Party:
Adverse Insurance:
Adjuster's Name:

Contact with adverse insurance?
YES    NO

Liability
Poor    Excellent

TREATMENT
Medical Provider(s):


Hospitalized?
YES    NO

Approximate amount of medical bills:


ISSUES AND COMMENTS:



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