Personal Injury Form

General Contact Information: 

First Name:

Last Name:

Street Address:

City:

State:

Zip:

E-mail Address:

Home Phone:

Work Phone:

Fax Number:

What method would you prefer we use to contact you?     Phone         E-mail       Fax

What time of day would you like us to call? Morning   Afternoon    Evening    N/A

General Incident Information:

On what date were you injured?

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:

Do you believe that any of your injuries are permanent? 

Yes   No   Not Sure

Employment and Earnings:

Have you lost any earnings due to your injury?  Yes    No

Are you still off work?  Yes    No    N/A

What type of work do you do? 

Before your injury, how much did you make per month? 

<$1,500                  $1,500-$3,000    $3,000-$5,000
$5,000-$10,000    > $10,000            N/A

Have you suffered any other losses because of this injury and, if so, please describe your losses:

If you were married at the time of the incident, has your spouse suffered any losses due to your injury?

Please describe:

Legal and Insurance Issues:

Have you contacted any other lawyer about your potential claim? Yes    No

If you answer yes to the previous question:

Did the lawyer agree to represent you?  N/A    Yes    No

Are you still being represented by the lawyer?  N/A    Yes    No   

Have you negotiated with any insurance company or any other person in connection with this claim? Yes    No

If you answer yes to the previous question:

Are negotiations still ongoing? N/A    Yes    No   

Additional Information:

Are there any other questions you wish answered?

Important Legal Disclaimers:

1. Yes     No - I agree that this matter may be referred to an attorney in my area who may contact me.

2. Yes     No - I agree that by submitting this question, I will not be charged for the initial response. I understand that I am forming only a semi-confidential relationship.

3. Yes - I agree No - I disagree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. 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. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.