Personal Injury Inquiry Form

Information About Who You Are and How We Can Reach You.

First Name
Last Name
Number, Street & Apt.
City
State
Zip
Day Telephone
Night Telephone
E-mail (Email address required for a response.)

Tell Us About the Person Who Was Injured.

Often the person contacting a lawyer is doing so on behalf of someone else, such as a parent or guardian on behalf of an injured child, or one spouse on behalf of the other, or even a friend or acquaintance attempting to assist someone else in obtaining counsel. Please provide the following information on behalf of person who needs assistance.

The following information is for myself: Yes No

If "no," my relationship to the following person is:

First Name
Last Name
Age
Occupation
How long engaged in this type of work?
Name and address of current or last employer
Highest grade or degree completed
Special training, certifications or experience:

Nature Of The Claim Or Injury?

Please provide a brief summary of the what happened and the nature and extent of the injuries and damages (200 words or less)

State the date of the accident or injury. (This is very important for determining the statute of limitations that may be applicable to any potential claims.)

• YYYY-MM-DD (e.g. 2000.12.01= December 1, 2000)

Where did the accident or injury occur?

Please fill in the city, county and state where it happened:

Who do you believe caused the accident or injury?

Provide the names and addresses of all the parties who you believe did something wrong (This may include the other driver, the manufacturer of the car, or equipment or product, the owner of property on which you were injured, etc.):

What damages were suffered (e.g., list the types of damages sustained -- medical expenses, lost wages, out-of-pocket expenses, etc., and the approximate amounts, if known at this point)

Describe the damages:

Is there anything else we should know?

Type in any additional information that you feel is relevant or which you feel we may need to know in order to evaluate your case:

When is the best time to reach you by telephone?

If the information you have provided is complete, please press the Send button below to send it to the Philip S. Coe Law Offices. Your information will be kept confidential.