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Derrick Accidents

Once you provide us with the following information, your free consultation form will be sent to an experienced personal injury forms for evaluation. That lawyer will review your Derrick Accident form in accordance with the site terms and conditions and may contact you to discuss your case.

Free Derrick Accidents Consultation

Title:
First Name:	*
Middle Name:
Last Name:	*
Home Phone:	*
Cell Phone:
Work Phone:
Email Address:
Address:	*
City:	*
State, Zip:	* *
What is the best way to reach you? Please provide the best place, time and method for contacting you.

Injured Person Information:

Date of Birth / Age: (ex. mm/dd/yyyy or 54)
Were you injured?	Yes No
If not, who are you inquiring on behalf of?

If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?

Is the person deceased?

Yes No

If deceased, what is the cause of death
as stated on the death certificate:

Date of Death: (ex. mm/dd/yyyy)
Was an autopsy performed?	Yes No
If not deceased, does the injury prevent you or the victim from working?	Yes No

If yes, when did you/victim stop working?
What is the approximate lost wages due to the injury?

Accident / Injury Information:

Date of Accident:	*
City where accident occured:	*
State where accident occured:	*
Occupation:

Name and Address of employer:

Describe Construction Site related injury:

Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:

Please explain the full extent of the victims injuries:

Comments / Additional Information
Is there anything else that would assist us in
understanding the facts of your case?

To Better Serve You:

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Please specify how you found us (if other than above):

If you found us using a search engine,
please tell us which search engine?

Please tell us exactly what terms you typed into the
search engine to find us? (i.e. Personal Injury Lawyers)

I understand that by filling out this free consultation form I am not forming an attorney client relationship. I understand that I may only retain an attorney by entering into a fee agreement and that by submitting this form I am not entering into a fee agreement. I understand that not all submissions may receive a response.
Yes No

I agree that the above does not constitute a request for legal advice. I agree that any information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. I agree that if this matter requires advice regarding my home state, local counsel may be contacted for referral of this matter. I understand that email is not secure and thus I am not forming a confidential relationship.
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I have read and agree with the TERMS AND CONDITIONS
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By Clicking the box below, I agree to submit my case for a free case evaluation:

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