Name
*
(So we know what to call you, and so we can run conflict checks.)
First Name
Last Name
Non-Work Phone
*
(Contacting us through a work phone may waive the attorney-client privilege.)
(###)
###
####
Are You Filling This Out for Yourself or Someone Else?
*
(If you're filling this out for someone else, we need to know who was injured and your relationship to them. This helps us determine who has the legal right to pursue a claim and how best to move forward.)
(If you're filling this out for someone else, please provide their name and your relationship to them.)
***If you're filling this out for an injured loved one, please answer the below questions as if you were them. If you're filling this out for a loved one who has passed away, please answer the questions from your own perspective.***
When Did the Incident Happen?
*
(This helps us determine if you are still within the legal time limit to file a claim. We say "incident" instead of "accident" because not all of our cases are accidents.)
MM
DD
YYYY
Where Did the Incident Happen?
*
(The location helps us determine the appropriate jurisdiction. We don't necessarily need the exact location yet. But, the more information the better.)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What Type of Incident Was It?
*
(Check all that apply so we understand the situation.)
How Did the Incident Happen?
*
(Tell us what happened in your own words. The more details, the better.)
What Injuries Did You Suffer?
*
(This helps us understand the severity of your case.) List all injuries (e.g., broken bones, concussion, traumatic brain injury, head trauma, back pain, neck pain, burns, emotional distress, post traumatic stress disorder, etc.):
What Medical Treatment Have You Received So Far?
*
(Medical treatment is critical to proving your injury case.)
What Ongoing or Future Medical Treatment Do You Expect to Need?
*
(Understanding long-term impact helps us determine case value.) List expected treatments (if known):
How Has This Injury Affected Your Life?
*
(We need to understand the full impact on your daily life, work, and relationships.)
In Your Own Words, How Has This Injury Impacted Your Life?
*
(Tell us how this injury has impacted your life in your own words. The more details, the better.)
Has an Insurance Company Contacted You About This?
*
(Insurance companies often try to settle for less than you deserve—let us know if they’ve reached out.)
What Are You Hoping We Can Accomplish for You?
*
(This helps us understand your goals for this case.)
Thank you! If you don’t hear from John within 2 business days, check your spam folder. If you don’t have anything in your spam folder, John is probably off fighting the forces of evil, and you should look for another lawyer.
