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Free North End Personal Injury Lawyer Consultation

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First Name: *
Middle Name:
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Address: *
City: *
State, Zip: *    *

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Please provide the best place, time and
method for contacting you.


Injured Person Information:

Date of Birth / Age:
(ex. mm/dd/yyyy or 54)
Were you injured? Yes    No
If not, who are you 
inquiring on behalf of?
If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?
Is the person deceased? Yes    No
If deceased, what is the cause of death
as stated on the death certificate:
Date of Death:
(ex. mm/dd/yyyy)
Was an autopsy performed? Yes    No
If not deceased, does the 
injury prevent you or the 
victim from working?
Yes    No
If yes, when did you/victim stop working?
What is the approximate lost wages
due to the injury?


Accident / Injury Information:

Date of Accident:   *
City where accident occured: *
State where accident occured: *
Please briefly explain the incident that
caused the injury:
Who do you believe was at fault in causing the
injury, and what do you believe they did wrong?
Describe the injuries in detail:
Do you believe the injuries are permanent? Yes    No


Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:
Please explain the full extent of the victims injuries:
Comments / Additional Information
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