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  Type Of Case: (REQUIRED)
General Contact Information:
Your Name: (REQUIRED)
Age of Injured Person:
Street Address:
E-mail Address: (REQUIRED)
Best time to contact you:
Phone Number: (REQUIRED) xxx-xxx-xxxx
Work Number: xxx-xxx-xxxx
Fax Number: xxx-xxx-xxxx
Type of Accident:
Legal Issues:
Have you contacted any other lawyer about your potential claim?
If you answered yes to the previous question: Did the lawyer agree to represent you?
Are you still being represented by the lawyer?
General Incident Information:
On what date were you injured (mm/dd/yyyy)?:
In what city and state did the injury occur?
Please briefly explain the incident that caused your injury:
Who do you believe was at fault in causing your injury, and what do you believe they did wrong?
Please briefly describe your injuries:
Were you taken to an emergency room:
If yes, which hospital:
Were you admitted as an inpatient to the hospital:
If yes, which hospital:
How many days were you an inpatient:
Do you require physical therapy for your injuries:
If yes, how often do you go to therapy:
Are you still treating with a physician:
What was the date of your last treatment (mm/dd/yyyy)?:
What is the name of the physician and/or specialist treating you for your injuries:
Do you believe that any of your injuries are permanent?
Employment and Earnings:
Are you currently collecting Workers' Compensation?
Have you lost any earnings due to injury?
Have you been released by a doctor to return to work?
Do you believe you are too injured to return to work?
Have you suffered any other losses (home, vehicles, etc...) because of this injury and, if so, please describe your losses:
Insurance Issues:
Have you notified Your Auto Insurance Company about this claim?
Name of Your Auto Insurance?
Do You have Health Insurance or Major Medical Insurance?
Name of Your Health Insurance?
Has the defendant's Insurance Company contacted you?
Name of the defendant's Auto Insurance?
For automobile-related accidents only:
Do you have PIP or MED PAY on your own policy?
Was a police report taken?
If yes, was it taken by the state police or the local police?
If local police, what is the name of the local police department:
Do you have a copy of the police report?
What was the damage to your vehicle?
How did you find our website:
Television Ad:
Radio Ad:
Newspaper Ad:
Referred by a Friend:
Search Engine:
Any Additional Questions?
Are there any other questions you wish to have answered?

Not Certified by the Texas Board of Legal Specialization
Principal Offices in Dallas, Texas

The information you obtain at this site is not, nor is it intended to be, legal advice.
You should consult an attorney for individual advice regarding your own situation.

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