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Name*

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Phone*

Email*

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What was the date of the injury or death?*

If you don’t know it, put your best guess.

What are the injuries?*

We only handle injury or death cases. Check all that apply.

Pain (e.g., neck/back pain)

Broken bone (no surgery needed)

Torn ligament/tendon (no surgery)

Surgery on a bone, ligament or tendon

A friend or family member was killed

Other significant injuries

No physical injuries

Did the injury or death happen in Florida?*

We only represent people for injuries or a death that happened in Florida (or on a cruise). However, if you live in Florida and the injury happened in another state, we may be able to represent you.

Yes, in Florida

No, outside Florida

No, on a cruise (including Florida cruises)

Please give us a brief description of the accident or incident.*

Put as little as you want. If you include more details — like what happened and whether it was work-related — I can more quickly tell if I can help.

Do you have an attorney?

Yes, I have an attorney

No. I had an attorney but I don’t have one now

No. I have not had an attorney

Attach any important photo(s)

For example, damage to vehicle(s), hazard that you tripped on, photo of incident scene, crash report, scarring or visible injuries, etc. (Optional – you can provide photos later if needed).

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