| First Name: |
|
|
| *Last Name: |
|
|
| Address: |
|
|
| City: |
|
|
| State: |
|
|
| Zip: |
|
|
| Home Phone: |
|
|
| Work Phone: |
|
|
| *E-mail Address: |
|
|
| |
| What time of day would you like us to call? |
| |
No Preference
Daytime
Evening |
| |
I. General Incident Information |
| Date you were injured. |
| |
|
| City and state incident occurred. |
| |
|
| Briefly explain events that caused your injuries. |
| |
|
| Briefly describe your injuries. |
| |
|
| Are any of those injuries permanent? |
| |
Yes No |
| Are any of the injuries substantiated by diagnostic tests, and if so, which tests? |
| |
|
| Who do you believe was at fault in causing your injury, and what do you believe they did wrong? [Note: We may be able to help you even if you cannot answer this question at the present time; however, your input will help us.] |
| |
|
| If you were involved in an automobile accident, were you covered by an insurance policy? |
| |
Yes No |
| If you were covered by an insurance policy, did you elect full tort or limited tort coverage? |
| |
|
| |
II. Employment and Earnings |
| Were you employed at the time of the incident? |
| |
Yes No |
| What was your employment at the time of the incident? |
| |
|
| Did the incident occur at work? |
| |
Yes No |
| Have you lost any earnings due to your injuries? |
| |
Yes No |
| Are you still out of work from your injuries? |
| |
Yes No |
| Before your injury, what was your monthly gross income? |
| |
|
| |
III. Legal and Insurance Issues |
| Have you contacted any other lawyer about your potential claim? |
| |
Yes No |
| If you contacted another lawyer, did the lawyer agree to represent you? |
| |
Yes No |
| If you contacted another lawyer, is that lawyer currently representing you? |
| |
Yes No |
| If the lawyer is not currently representing you, please tell us the circumstances under which your relationship with that lawyer terminated. |
| |
|
| Have you negotiated with any insurance company or any other person in connection with this claim? |
| |
Yes No |
| If you answered yes to the previous question, are negotiations still ongoing? |
| |
Yes No |
| |
IV. Legal Disclaimer |
| I agree that by submitting this information for evaluation, I will not be charged for the initial response. I further understand and agree that the above does not constitute a request for legal advice and that I am not forming an attorney-client relationship by submitting this information for evaluation. 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. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter. |
|
