| | * required |
| *Full Name: |
|
| *Date of Birth: |
|
| *Street: |
|
| *City/State: |
|
| *Zip: |
|
| Email: |
|
| *Phone: |
(
)
-
|
| Other Phone: |
(
)
-
|
| Marital Status: |
|
| Name of Spouse, if any: |
|
| Occupation: |
|
| Highest level of education: |
|
Please provide a brief overview of the
legal matter you need assistance with: |
|
Injury Cases |
| If you need assistance with an injury matter (including wrongful death claims, product liability claims and malpractice claims) please submit the following as well. |
| |
| City and State in which you were injured: |
|
Name(s) of the person(s)
who you allege caused you injury,
and their addresses, if known: |
|
| Please describe your injuries: |
|
Please describe any treatment
you have had so far: |
|
| Are you still being treated for your injuries? |
|
If yes, what kind of treatment
are you now getting and/or do
you anticipate in the future? |
|
| What is the approximate amount of your medical bills thus far? |
|
| Have you been forced to miss work? |
|
| If so, how much in lost wages and/or benefits hare you sustained? |
|
Have you been contacted by any
insurance company regarding your injuries? |
|
If so, what is the name and
address of the insurance company and
adjuster(s) you have talked to? |
|
Are you currently represented
by another lawyer? |
|
If so, please give us the
attorney's name, address and phone
number: |
|
| If you ARE NOT the injured party and if you have filled this information out for someone else, and are not the person in need of assistance, please answer the following: |
| |
| Full Name |
|
| Street Address: |
|
| City, State, Zip |
|
| EMail |
|
| Home Phone |
|
Please describe your relationship
to the person in need of assistance: |
|
| For parents of guardians, if the person in need of assistance is not a minor or disabled, we will need to communicate directly with that person regarding our review
, in order to maintain attorney/client confidentiality. If the person in need of assistance is a minor or is a disabled adult with an appointed guardian, we will need
to communicate with that parent or guardian. With this in mind: |
| |
Who is the person to be contacted
after we have completed our review? |
|
What is the best time
to contact that person? |
|
What is the best way to contact
that person? (e.g., email, phone etc.) |
|
| |
|
