Case Review Request

Full Name*
Email Address*
Phone*
Address Line 1*
Address Line 2
City*
State*
Zip*
Please provide a brief personal background of the person needing assistance. Many times we are contacted by someone other than the person in need of help, such as a parent on behalf of a child, or wife on behalf of a husband. Please provide the following information on behalf of the person who needs assistance.
The following information is for myself:
- Yes
- No
If "No" my relationship to the following person is:
First Name
Last Name
Age
Occupation
For how long?
Current or last employed
City (Last employed)
State (Last employed)
Highest grade completed
Schools/College attended
Degrees
Year granted
Special training or experience in
Why do you need help? Please provide us with a very brief overview, in 200 words or less, describing in general the subject matter of your request. You can provide more detailed information below, but for now please confine yourself to providing us with a brief statement of the general facts of your case, injury and damages.
Brief statement on general facts of case, injury and damages
Date injured
What occurred
Where did it happen?
City
State
County
Who caused the harm? Please type in the names & addresses of all the wrongdoers involved:
What damages were suffered? Describe the damage you have suffered:
Has anyone already filed a suit?
- Yes
- No
When is the best time to reach you by telephone?
When the information you have provided is complete, please press the Submit button below to send it to our firm. Your information will be kept strictly confidential.
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