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Case Evaluation

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

*Full Name

*Date of Birth

*Full Address

*E-Mail

Phone

Please provide an 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.

Please describe your injuries.

Please describe any treatment you are presently receiving or have received for your injuries.

What is the approximate amount of your medical bills thus far?
$

If you have missed work due to your injuries, how much in lost wages and/or benefits have you sustained?
$

If you are currently represented by another attorney, please provide 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

Home Phone

Relationship to the person in need of assistance (e.g. parent, spouse, friend)

By submitting this form: I agree that this matter may be referred to an attorney who may contact me. I agree that by submitting this query and/or question I will not be charged for the response. I also understand that I am not forming an attorney-client relationship with your law firm. I agree that the above does not constitute a request for legal advice. I understand that I may retain your firm's services by entering into a fee agreement, and that I am not now entering into such an agreement. I agree that the information that I will receive from you in answer to the above question is general information only and without charge. I further understand that the law for each state is different, and I will not rely upon this information as legal advice.

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