Name: *


Address: *


State: *


City: *


Zip: *


Email: *


Phone: *


Relationship to the deceased: *
parent spouse sibling other

Have you or your loved one received any settlement money from this claim? *
Yes No

Was the injury due to someone else's negligence? *
Yes
No

Have you already filed a personal injury *
Yes No

Was an ambulance called? *
Yes
No

Do you have copies of your medical records? *
Yes
No

Do you have an attorney assisting you with this claim? *
Yes No

Did you or loved one seek medical treatment for injuries? *
Yes
No

Did the injury occur within the past three years? *
Yes
No

Date of Wrongful Death Incident: *


Amount of medical bills? *
0
Less than 2,499
2,500-4,999
5,000-14,999
15,000-24,999
25,000-49,999
50,000 +

A brief description of the situation: *


I understand that submitting this form and the information contained herein does not constitute a Consultant/Attorney/Client relationship. I understand the response to the above question is general information and I will not be charged. I understand that state laws may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter. *

Any additional comments *