Client Qualification Form

Injury and Treatment

Were you injured or are you interested in pursuing treatment related to an incident that occurred within the last 14 days?(Required)

Yes

No

Fault

Do you believe that you were NOT at fault for the incident?(Required)

Yes

No

Legal Representation

Are you currently represented by an attorney for this incident?(Required)

Yes

No

Statute of Limitations

Have you been informed that your claim is barred by the applicable statute of limitations?(Required)

Yes

No

Insurance Coverage

Have you been told that there is no insurance coverage for the loss?(Required)

Yes

No

Moving Violation

Were you cited for a moving violation related to this incident?

If yes, was the citation dismissed or dropped?(Required)

Yes, cited and dismissed/dropped

No citation received

Yes, but not dismissed/dropped

Previous Legal Representation

Have you been dropped or discharged by a previous attorney due to a lack of insurance coverage or being deemed at fault for the incident?(Required)

Yes

No

Uninsured/Underinsured Motorist Coverage

Do you believe you have uninsured or underinsured motorist coverage?(Required)

Yes

No

Was the accident a hit and run where you cannot provide identifying information (name, license plate number, company name, etc.) for the at-fault party?(Required)

Yes

No

Complete Your Submission

Please provide your contact details for the final step.

First name(Required)

Last name(Required)

Phone Number(Required)

Email Address(Required)

Referral Source(Required)

Describe your incident(Required)

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Comments

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