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Catastrophic Injuries Inquiry Form
Title: First Name: MI: Last Name:
E-mail Address:
Retype E-mail:
Home Phone:
 - -
Mobile Phone: - -
Work Phone: - - ext.
   
   
Street Address:
Apt/Suite:
City:
State/Zip: /

What is the best way to reach you?
Please provide the best place, time and method for contacting you.



Injured Person Information  
Date of Birth:  
Whom are you inquiring on behalf of?  
What is your relationship to the Injured person?
Is the person deceased? yes no  
If deceased, the cause of death
as stated on the death certificate:
Date of Death:  
Was there an autopsy performed? yes no  
Catastrophic Injury Case Information
How Did Accident Happen?:


Tell Us About Your Injuries:
  
Anything Else You Would Like To Tell Us:
  
Are You Disabled? Yes No  
Lost Earnings:  
Date of Incident:  
Disclaimers:

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

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.

Yes - I 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 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.


By Clicking the appropriate box below, I agree to:

or

 

  		 

 
 

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