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Type of Legal Help Needed:*
Zip Code:*
VID

Do You Currently Have an Attorney?*

YesNo
Total Monthly Income?*
Total Debt?*
Own Real Estate?*
Marital Status:*
Do You Have Children?*

YesNo
Value of Your Assets?*
Any Prior Alcohol Related Offenses?*

YesNo
Type of Alcohol Test Performed?*
Blood Alcohol Content Measured by Test:*
Status of Claim:*
Date of Incident:*
Were You Hospitalized or Treated by a Doctor?*

YesNo
Were You at Fault?*

YesNo
Primary Injury:*

AnxietyBack or Neck PainBroken BonesCuts and BruisesHeadachesMemory LossLoss of LimbOther (describe on next page)
Cause of Injury:*
What is Your Role in this Matter?*
Are You Seeking Expungement?
What Type of Charge?*
Country of Citizenship:*
Immigration Issue:*
The Person with the Immigration Issue Is:*
What is the Applicant's Occupation?*
Age of Applicant?*
Does Applicant have a Long Term Disability Policy?*

NoYes
How Did Applicant Obtain the Disability Policy?*
Has Applicant Previously Applied for Long Term Disability Benefits?*

Yes, claim pendingYes, claim deniedNo
Has Applicant Ever Received Long Term Disability Benefits for this Claim?*
Applicant's Monthly Salary/Pay When Last at Work:*
When Did Your Condition First Begin to Affect You?*
Has Your Condition Caused You to Stop Working or Substantially Reduce Your Work Hours?*
Have You Worked at Least 5 of the 10 Past Years?*

YesNo
Have You Applied for Social Security Disability?*

Yes, claim pendingYes, claim deniedNo
Are You Currently Receiving Social Security Disability Benefits?*

YesNo
Are You Currently Being Treated by a Doctor?*

YesNo
Was a Police Report Filed?*

YesNo
Total Employees of Business? (estimated)*
The Employer Is a:*
Injuries from Medical Malpractice:*
Type of Driver's License:*

PrivateCommercial
Traffic Violations:*

DUI/DWISpeedingDisregarding a Stop SignDisregarding a Red LightDMV Letter About LicenseFailure to Appear in CourtLicense Suspended/RevokedMinor in Possession of AlcoholNo Child Safety SeatNo Liability InsuranceNo Seat BeltOpen Container of AlcoholRacingUnpaid Traffic TicketsWarrant Issue for ArrestOther Violation
Do You Have a Court Date?*

YesNo
Type of Assets:*

Business InterestsCashLife Insurance PoliciesPensions/RetirementPersonal PossessionsPropertyStock/Bonds
Total Amount of Assets:*
What Is Your Role in this Matter?*
Relationship to the Victim:*
Were Criminal Charges Files?*

YesNoNot Sure
What was the Cause of the Victim's Death?*
Type of Property:*
Total Amount of Payments that are Past Due:*
Total Amount of Loan?*
Have You Received a Notice of Default from the Lender?*

YesNo
Area of Real Estate:*
I Would Like a Lawyer to:*
Legal Services Needed for Your Estate:*
Has the IRS reached out to you about the issue?*

YesNo
Type of Tax Issues:*

IncomeEstateBusinessOther
Would You be Willing to Pay for a Law Firm to Assist?*
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How Will You Pay Legal Fees If You Hire Lawyer?*
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Please provide any additional details of your legal issue below.*

First Name*
Last Name*

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Email*
Phone Number*
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Need Legal Help? Start Here. It's FREE!

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