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Tuesday, March 9, 2010

Aggressive and Intelligent Representationcall today 602.910.6144 or 1.888.349.3599

Case Form

Use this email form to obtain a free consultation concerning the legal needs and issues which you have and we will determine whether we can assist you.

We should respond to you promptly. If you prefer to speak directly to someone in our office or have questions about this form, please call us toll free at 602.910.6144 or call us toll free at 1.888.349.3599.

To expedite your case evaluation, we encourage you to provide us with your name, phone number, and email address, so that one of our representative can contact you to get any additional information that may be needed.

NOTE: An asterisk (*) indicates REQUIRED information.

Use this email form to obtain a free consultation concerning your personal injury case and we will determine whether we can assist you.

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Who was injured?

If "Other," please describe:

Injured person's name (if different from above):

Address:

City:

State:

Zip:

E-mail address:

Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

When did the injury occur?

Where did the injury occur?

Was this location the injured person's

If "Workplace," did the injury occur as a result of employment activities?
Yes  No 

If "Other," was this a road accident?
Yes  No 

If no, did the injury occur on another's property?
Yes  No 

If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?
Yes  No 

If yes, what are the witnesses names/contact information?

Were others involved or injured at the same time?
Yes  No 

If yes, what are their names/contact information?

Was there a police report?
Yes  No 

Did the injured person receive medical treatment?
Yes  No 

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
Yes  No 

Was the injured person killed as a result of the accident?
Yes  No 

If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

Where did you hear about this website?

The contents of this contact form are provided by and are the responsibility of the person posting the email communication. Your email will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. You acknowledge that any reliance on material in email communications is at your own risk.
A Law Firm You Can Trust - Established in 1979, our firm's primary goal is to provide first rate legal services on time and for a reasonable rate.