


	• Auto Accidents • Aviation Accidents • Bicycle Accidents • Boating Accidents • Brain Injury • Burn Injury • Construction Accidents • Defective Products • Insurance/Bad Faith • Maritime Law • Motorcycle Accidents • Nursing Home Abuse • Pedestrian Accidents • Premises Liability • Spinal Cord Injury • Train Accident • Truck Accident • Wrongful Death

We offer a free 30 minute consultation on all Litigation claims. We will carefully review your case and determine the strength of your case.

Please complete and submit the online form below

There is no charge for this consultation and no obligation to use our services.

Type Of Accident:

General Contact Information:
Your Name: (REQUIRED)
Age of Injured Person:
Street Address:
City:
State:
Zip:
Email Address: (REQUIRED)
Phone Number: (REQUIRED)
Work Number:
Fax Number:

Legal Issues:
Have you contacted any other lawyer about your potential claim?	Yes No
If you answered yes to the previous question: Did the lawyer agree to represent you?	Yes No
Are you still being represented by the lawyer?	Yes No

General Incident Information:
On what date were you injured (mm/dd/yyyy)?:
In what city and state did the injury occur?
Please briefly explain the incident that caused your injury:
Who do you believe was at fault in causing your injury, and what do you believe they did wrong?
Please briefly describe your injuries:
Were you taken to an emergency room:	Yes No
If yes, which hospital:
Were you admitted as an inpatient to the hospital:	Yes No
If yes, which hospital:
How many days were you an inpatient:
Do you require physical therapy for your injuries:	Yes No
If yes, how often do you go to therapy:
Are you still treating with a physician:	Yes No
What was the date of your last treatment (mm/dd/yyyy)?:
What is the name of the physician and/or specialist treating you for your injuries:
Do you believe that any of your injuries are permanent?	Yes No

Employment and Earnings:
Are you currently collecting Workers' Compensation?	Yes No
Have you lost any earnings due to injury?	Yes No
Have you been released by a doctor to return to work?	Yes No
Do you believe you are too injured to return to work?	Yes No
Have you suffered any other losses (home, vehicles, etc...) because of this injury and, if so, please describe your losses:
Insurance Issues:
Have you notified your insurance company about this claim?	Yes No
Has the defendant's insurance company contacted you?	Yes No
For automobile-related accidents only:
Was a police report taken?	Yes No
If local police, what is the name of the local police department:
Do you have a copy of the police report?	Yes No
What was the damage to your vehicle?

How did you find our website:
Source:	Referred by Friend Referred by Friend
Any Additional Questions?
Are there any other questions you wish to have answered?

Note: This online inquiry does not establish or represent an attorney-client relationship. Rather, the information you submit to us allows us sufficient data for follow-up calls. All agreements to represent clients are by way of a written contract with this firm. The response to an e-mail inquiry does not mean that this law firm has agreed to represent you in this or any other matter.