Injury and Disability Form

*Name:

*Address:

*City:

*State:
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*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Are you known by any other names?
Yes  No 

If yes, list other names you have used:

What is your marital status?
Choose One Single Married Divorced Separated Widowed

Does this matter involve a business you own or run?
Yes  No 

If yes, provide the business name, address, and phone:

If a business is involved, how is the business organized (if known)?
Choose One Sole Proprietorship Partnership Limited Liability Company Limited Partnership Professional Corporation S Corporation C Corporation Other

Are you employed?
Yes  No 

If yes, please provide your job title and employer's name and address.

Can you be contacted at work?
Yes  No 

What area of law does your situation involve (if known)?
Choose One Administrative Law Admiralty / Maritime Law Adoption Agriculture Law Alternative Dispute Resolution Animal Bites Antitrust & Trade Regulation Aviation Aviation & Mass Transit Accid. Banking / Finance Law Bankruptcy Law Business & Commercial Law Business Organizations Child Support Civil Rights Construction Law Consumer Protection Contracts Criminal Law Criminal Law / Federal Custody / Visitation Discrimination Divorce DUI / DWI Education Law Elder Law Employment Law / Employee Employment Law / Employer Energy Law Environmental Law Estate Planning Ethics/Professional Resp. General Franchising Government Agencies/Programs Govt. Contracts Health & Health Care Law Immigration/Naturalization Insurance Law Intellectual Property Law International Law Internet/Cyberspace Labor Law Landlord / Tenant Legal Malpractice Litigation / Appeals Medical Malpractice Law Military Law Motor Vehicle Accidents Nursing Home Patent Personal Injury Personal Injury/Defense Premises Liability Probate Estate Administration Products Liability Law Professional Malpractice Law Real Estate Law Science/Technology Law Securities Law Sexual Harassment Social Security/Disability State/Local/Municipal Law Taxation Law Toxic Substances Trademarks Traffic Violations Transportation Law Trusts Wills Workers' Compensation Law Wrongful Death

Describe your situation, including any relevant dates:

How would you rate your legal needs described here?
Choose One Extremely Urgent Urgent Standard Informational Only

Are any other people involved?
Yes  No 

If yes, provide names, addresses (if known), and their relationship to you, if any:

Do you have any documents that could help explain your situation?
Yes  No 

If yes, list those documents and their dates:

Are there other documents that you do not have access to that could be of assistance?
Yes  No 

If yes, list those documents and their dates and locations (if known):

Describe how this situation has impacted you:

Describe what you would like to happen to resolve your issue (your preferred outcome):

Have other attorneys worked on this matter?
Yes  No 

If yes, provide names, addresses, and a brief description of their involvement:

Special concerns:

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