You are in no way entering a legal agreement by completing this questionaire. You are also in no way required to retain the lawyer who examines this case. Finally, the lawyer who completes your case evaluation is not obligated to work on your case; unless he or she agrees so in writing.

Required fields are indicated by an asterisk (*)

   
     

Name *

     
      Address        
      City *        
      Postal Code        
      Phone *  
(ex. 613-555-1234) 		     
      Email Address *        
      Age        
      Referred By        
      Names of Parties Involved        
      When did your injury occur?  

(Notice of claim must be provided to the Defendant within 120 days of the incident; to own insurer within 7 days) 		     
     
How was the injury caused? Provide as much detail as you can.
Include your view with respect to who is at fault.

     
     
What is the nature of your injuries? Be as detailed as possible.

     
     
What are your ongoing problems?

     
     
Have you suffered any income loss as a result of your injuries?



     
     
Please provide us any other information you feel we need to know at this time.