Do You Have a Case?

Do You Have a Case?

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Below is an evaluation form concerning your potential auto accident case. We promise a qualified member of our firm will respond in a timely manner to every evaluation form you submit to us. Do not wait in letting us know of your potential case. Whether or not we are able to assist you and your case, you will receive a quick response from us. Our review of the documentation you send us does not constitute an attorney-client relationship. Your submission of this evaluation form does not mean we are representing you or that we are your lawyers.

First Name Last Name

Street Address

City

State

Zip/Postal Code

Work Phone

Home Phone

FAX

E-mail

Were you injured?

Yes
No

If "no" who is the injured party:

Name
Date of Birth

What is their relationship to you?

What is the nature of your injury?

Incident Date:

-- mm/dd/yy

Incident Location:

Any Passengers?

Yes
No

Names and phone numbers of all the passengers:

Person/Company responsible:

Why do you think the other party is at fault?

How can we help you?

Who is the responsible party's insurance company?

Do you have uninsured motorist coverage on the date of the accident?

Yes
No