Douglas & and London, P.C. - Free Case Evaluation

If you believe that you or someone close to you may have a personal injury or wrongful death claim, please fill out and submit the form below for a free evaluation.

Use the drop down below to find the topic you are inquiring about. If you
do not find the topic you are looking for, please fill out the form below

* Required Fields.

There is no charge for this evaluation

*Title:**	*First Name:**	MI	*Last Name:**

*E-mail Address:**		(ex. johndoe@anywhere.com)
*Home Phone:**		(ex. 505-555-5005)
Work Phone:		(ex. 505-555-5005)
Mobile Phone:		(ex. 505-555-5005)
Street Address:
City:
State / Zip:	/	(ex. NY / 10005)

Injured Person Information:

Date of Birth:

Whom are you inquiring on behalf of?

If you are NOT inquiring on your own behalf,
what is your relationship?

Is the person deceased?
Yes No

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

Date of Death:

Was there an autopsy performed? Yes No n/a

Injury/Case Information:

Please decribe your case and/or injury:

Date of Incident:

Yes No - I agree that by submitting this question, I will not be charged for the initial response. I understand that I am forming only a semi-confidential relationship.

Yes - I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. I agree that the 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. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.

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