We are willing to evaluate your potential personal injury case and discuss its merits and value with you. There is no charge for our preliminary evaluation and discussion, but we do need certain information from you to perform our evaluation. Once we receive the information requested below, we will contact you to discuss our evaluation. Again, there is no cost to you whatsoever for this case evaluation.

If you are interested in receiving help on your potential personal injury claim, please provide us with the information requested below. Please be sure to provide us with as much information as is reasonably available. The quality of our evaluation is dependent upon the accuracy of the information you provide to us.

(Note: If you would rather fill out the short form and have an attorney ask you the below questions please click here.)

Your full name:


E-mail Address:


  (Required) Mailing Address:




Home Number:


Work Number:


Best time to reach you if you prefer a response by telephone:


How would you like for us to respond to you (e.g., telephone, e-mail, regular mail, doesn't matter)?


Type of Personal Injury:

On what date were you injured?


Where were you hurt (City, State)?


Describe the accident which caused your injury as fully as possible:


Who do you believe was a fault in causing your injury, and what do you believe they did wrong?


Do you have any other information which you believe would help us help you?


Describe your injuries. If you know, state whether you have a permanent injury. If you know, what are your total medical bills to date?


Have you lost any earnings? Are you still off work? What kind of work do you do, and how much do you earn per week or per month?


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


Were you married when the injury occurred and, if so, has your spouse suffered any loss or damage because of your injury?


Have you contacted any other lawyer about your potential claim and, if so:

Did the lawyer agree to represent you?


Are you still being represented by the lawyer?


Are you now seeking a lawyer to represent you, or are youjust looking for a second opinion?


Do you owe any other lawyer a fee in this matter?


If we are willing to represent you, do you wish to employ us?


Have you negotiated with any insurance company or any other person in connection with this claim and, if so:

Are negotiations still ongoing?


What was the lowest settlement amount that you asked for?


What was the highest amount that you have been offered to settle?


Have the medical or funeral bills or lost wages been paid for by:
Workers Compensation?
Medicare, medicaid, or some other government program?
Employer's health plan?
Private insurance?


Are there any other questions you wish answered?


Is there any other information that you want to provide us?


Would you like to arrange a personal interview?


Are there any other instructions you wish to give us?


If you are finished, agree with the above, and want to send this information by e-mail:


If you want to start over to correct or change information:

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