Submit Your Case Online

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General Contact Information  
Type of Case:
*Name:
Age of Injured Person:
Street Address:
City:
State:
Zip:
*Email Address:
Best Time to Contact:
*Phone Number:
Work Number:
Fax Number:
Type of Accident:
Legal Issues  
Have you contacted any other lawyer about your potential claim?
If yes, did the lawyer agree to represent you?
Are you still being represented by the lawyer?
General Incident Information  
On what date were you injured (mm/dd/yy)?
In what city and state did the injury occur?
Please briefly explain the incident that caused your injury:
Who do you believe was at fault in causing your injury, and what do you believe they did wrong?
Please briefly describe your injuries:
Were you taken to an emergency room:
If yes, which hospital:
Were you admitted as an inpatient to the hospital:
If yes, which hospital:
Do you require physical therapy for your injuries:
If yes, how often do you go to therapy:
Are you still treating with a physician:
What was the date of your last treatment (mm/dd/yyyy):
What is the name of the physician/specialist treating you:
Do you believe that any of your injuries are permanent?
Employment and Earnings  
Are you currently collecting Workers' Compensation?
Have you lost any earnings due to your injury?
If yes, what amount:
Have you been released by a doctor to return to work?
Have you suffered any other losses because of this injury and, if so, please describe your losses:
Insurance Issues  
Have you notified your insurance company about this claim?
Has the defendant's insurance company contacted you?
Auto-related Accidents Only  
Was a police report taken?
If yes, was it taken by the state police or the local police?
If local police, what is the name of the local police department?
Do you have a copy of the police report?
What was the damage to your vehicle?
Additional Questions  
How did you find our website?
Are there any other questions you wish to have answered?

              

Thank you for allowing The Barber Law Firm, P.C. to provide you with a free evaluation of your injury claim. Please remember:

  • Many times, in order to give you a complete evaluation of your claim, we will need to speak with you on the telephone.  Therefore, when completing the information above, please be sure to provide us with a telephone number where you can be reached.
  • Submission of this form and the information contained in it is not privileged nor is it intended to create an attorney-client relationship between the sender and The Barber Law Firm, P.C..
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  • Your information will be reviewed during normal business hours, M-F 8:00am - 5:00pm.