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.

Bold labels and indicate required information.

Personal Information

Name : Please enter your name

Address : Please enter your Address

City : Please enter the name of your City

State : Please enter the name of your State Select State : Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip : Please enter the Zip Code

Email address : Please enter a valid e-mail address.

Home Phone : Please enter a valid e-mail address.

Business Phone :

Cellular or Pager :

Facsimile :

Who was injured : Choose One Me Family Member Other If Other, please describe :

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

Address :

City :

State : Select State : Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip :

Email 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 Select Was this location the injured person's Workplace School Home Other

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?

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) :

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