Zwiebel & Fairbanks

Premises Liability 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

Premises Injury Case Information

Date Of Your Injury

Where were you injured?

Who owns the premises?

Why Were You There?

What injuries did you sustain?

Anything Else You Would Like To Tell Us:

Have you been disabled? Yes No

Have you been there before the accident? Yes N

Did the owner or person responsible know about the danger? Yes No

Last Date of Work

How much time have you lost from work?

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

Serving all of New York State -with experience in the Federal courts and State courts covering the counties of Albany, Brooklyn, Kings, Bronx, New York, Manhattan, Dutchess, Orange, Rockland, Sullivan, Ulster, Greene, Columbia, Rennselaer, Washington, Saratoga, Fulton, Montgomery, Nassau, Suffolk, Warren, Essex, Clinton, St. Lawrence, Onandoga, Erie, Broome, Delaware, Otsego, Oswego, Hamilton and Westchester

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72 Maiden Lane, Kingston, NY 12402 | 125 Wolf Road, Albany, NY 12203