Contact Us

Contact Us About Your Personal Injury Issue

*Your name:   
 
Name of Injured/deceased person,
if not you		   
 
Address:   
 
City:   
 
State:   
 
Zip:   
 
Date of Birth:   
 
Phone:   
 
 
*Email Address:   
 
When did the injury take place?   
 
Where did the injury occur?   
 
Did the injury occur while you were working?    Yes  No 
 
If so, name and
address of your employer.		   
 
Did the accident involve
a motor vehicle or motorcycle?		    Yes  No 
 
Did the injury occur
on someone else's property?		    Yes  No 
 
If so, who owns the property
where the accident occurred?		   
 
Did the injury occur due to
a defective product of some kind?		    Yes  No 
 
If so, what product
caused your injury?		   
 
Please give a detailed description of the accident.

 
Were there any witnesses to the accident?    Yes  No 
 
Was a police report prepared?    Yes  No 
 
Describe all injuries you sustained.

 
List the names of your medical providers and the dates
of any hospitalizations, MRIs, CT scans or surgeries.

 
Have you lost time from work?    Yes  No 
 

THE FOLLOWING QUESTIONS APPLY ONLY TO THOSE WHO HAVE APPLIED, OR ARE INTERESTED IN APPLYING, FOR SOCIAL SECURITY DISABILITY:
 
If you are not currently working due to an
injury, illness or other disability, have
you applied for Social Security Disability?		    Yes  No 
 
If you have applied for Social Security
Disability, was your claim denied?		    Yes  No 
 
If your claim was denied, when did you
receive notification that your claim was
denied?		   
 
What is the highest grade
of school you completed?		   
 
On what date were
you last employed?		   
 
If you have applied for Social Security Disability, please list
all of the types of work you have done over the last 15 years.

 
Describe in detail all of your disabilities and
why they keep you from working.

 
How did you find our website?