• Seeking Legal Guidance After an Accident?

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• Name*
  First NameLast Name
• Email*
• Phone Number*
• Zip Code*
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• Were you or a loved one a victim of an accident?*
  YesNo
• Who sustained injuries in the accident?*
  I was injuredA friend or loved one was injuredWe were both injuredNo one was injured
• Are you currently experiencing any ongoing pain or limitations due to the accident?*
  YesNo
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• Are you currently being represented by a lawyer?*
  YesNo
• Are you looking to switch representation for this accident?*
  YesNo
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• When was the date of your accident?*
   /Month /DayYear
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• What type of accident ocurred?
  Vehicle AccidentSlip & Fall / Trip & FallConstruction AccidentMedical MalpracticeOther
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• What was your role in the accident?*
  Automobile DriverMotorcyclistPassengerBicyclistPedestrian
• What type of vehicle collided with you?*
  SedanSUVState / City VehicleWork VanTruckBusConstruction Machinery
• What kind of vehicle accident would it be considered?*
  Rear EndHead-On CollisionIntersection with a Stop SignIntersection with a Traffic LightSideswipeRolloverMulti Vehicle Accident
• Did the police come to the scene and write a police report?*
  YesNo
• Did anyone witness the accident, or were there security cameras in the vicinity?*
  YesNo
• Did the accident happen while you were at work?*
  YesNo
• Was medical treatment received due to the injuries sustained in the accident?*
  YesNo
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• Where did the injury occur?
  Commercial Property (e.g., store, restaurant, office building)Residential Property (e.g., home, apartment)Storefront or Business PremisesPublic Sidewalk or WalkwayRecreational Facility (e.g., gym, swimming pool)Parking Lot or Garage
• What caused your fall?
  Poor LightingUneven or Damaged Floor SurfaceWet or Slippery Surface (e.g., liquid spill, ice, grease)Obstructed Pathway (e.g., debris, objects in the way)Inadequate Signage or WarningsUneven Steps or StairsDefective or Poorly Maintained Flooring (e.g., loose tiles, torn carpet)
• Did anyone witness you fall, or were there security cameras in the vicinity?*
  YesNo
• Did the accident happen while you were at work?*
  YesNo
• Was an incident or accident report filed?*
  YesNo
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• Did anyone witness you fall, or were there security cameras in the vicinity?*
  YesNo
• Was an incident or accident report filed?*
  YesNo
• Can you provide details about the incident?
  Ladder Accidents and FallsScaffolding AccidentFall From HeightsFalling ObjectElectrocutionConstruction Machinery IncidentStuck In Between EquipmentDeathOther
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• Where did the injury occur?*
  Private PracticeHospitalAmbulatory Surgical CenterNursing HomeHospice
• Who do you believe was negligent?*
  Physician / SurgeonNursePhysician AssistantNurse’s AideResident
• Has a doctor confirmed your belief that something went wrong?*
  YesNo
• Can you provide details about the incident?*
  Delay / Failure to Diagnose or TreatMissed Cancer DiagnosisProblems After SurgeryDisfigurementInfectionForeign Object Left BehindIncorrect Drug AdministeredMedical Device RecallDeath
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• Tell Us About Your Accident
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• Do you have a language preference for your lawyer?*
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• What time of the day is best to contact you?
  Morning (8:00am - Noon)Afternoon (Noon - 4:00pm)Evening (4:00pm - 8:00pm)After Hours (8:00pm - Midnight)
• Do you need a ride to your initial consultation?
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