Please feel free to submit a case evalutation. Fields with * must be filled in.

* Full Name
* Email Address
* Phone Number
Cell Number
Address including City, State, & Zip Code
Date of Birth of Injured Person
State Where Accident/Incident Occurred
Describe Accident/Incident and Injuries
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Submit A Free Case Review

Please fill out the following for a free case review. The information submitted will be accorded the utmost confidentiality. This information is necessary in order to do a conflict of interest check before responding to you. If you prefer, you may contact us at Toll Free at (800) 352-HURT.

Please provide the following information for the person in need of assistance. Fields with (*) are required.

*Full Name

*Date of Birth

*Street Address

*City, State, Zip

E-Mail

*Home Phone

Other Phone

Marital Status
Married
Single
Separated
Divorced
Widowed

Name of Spouse, If Any

Occupation

Highest Level of Education Attained
High School
Some College
4 Year Degree
Advanced Degree

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 information 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?
Yes
No

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 due to your injuries?
Yes
No

If so, how much in lost wages and/or benefits have you sustained?

Have you been contacted by any insurance company regarding your injuries?
Yes
No

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?
Yes
No

If so, please give us the attorney’s name, address and phone number.

If you Are Not The Injured Party

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

E-Mail

Home Phone

Please describe your relationship to the person in need of assistance (e.g. parent, spouse, friend)

For Parents or 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., e-mail, phone, letter)

After the information is complete, please press the submit button. We will review the information and contact you as soon as we have done a conflict of interest check.





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