Do I Have a Case?

If you have been injured by the negligence of someone else, please take a moment and fill out this brief questionnaire. One of our attorneys will contact you after we review your information.

Please take a moment to fill out this form. When you have completed the form, click the "submit" button and a member of our staff will contact you to discuss your case as soon as we have reviewed your information.

PLEASE DO NOT GIVE A WRITTEN OR RECORDED STATEMENT TO THE INSURANCE COMPANY WITHOUT FIRST CONSULTING AN ATTORNEY.

Questionnaire

Accident Information
    
Date of Accident:
 
Time of Accident:
 
Location of Accident:
Were there any tickets given?:
 
Yes    No
If Yes, who received the ticket?:
  
What type of Injuries do you have?:
  
Name of other person's insurance:
  

Please give a detailed description of your accident:

Contact Information
* Indicates a required field.

* Your Name:
   Mr. Mrs. Ms. Dr.
Marital Status:
   Single Married  Divorced Separated Widowed
* Address:
  
* City:
  
County:
  
* State:
  
* Zip:
  
* Home Phone:
  
Work Phone:
  
Cell Phone:
  
* E-mail:
  
* SPAM CHECK:
  

Please type the numbers 1, 2, and 3
in the field above using no commas and no spaces
* Yes, I have read and agree to the Joel Bieber Firm disclaimer

Please review your information before sending.

** Electronic Form Submissions

The mere submission of a contact form does not necessarily form an attorney-client relationship with the Joel Bieber Firm. However, if my case is evaluated and I receive a response from the firm, I understand that an attorney-client relationship will be formed. If I do not receive a response, my case was not evaluated; hence an attorney client relationship has not been formed.

If you send us information electronically via this website, you agree that our review of that information, even if you submitted it in a good faith effort to retain us, and, further, even if it is highly confidential, does not preclude us from representing another client directly adverse to you, even in a matter where that information could and will be used against you.

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. Due to the reach of the internet, this matter may require advice regarding my home state; I agree that local counsel may be contacted for referral of this matter.

I understand that additional disclaimer information is viewable under the disclaimer headline (Terms of Use & Privacy Policy) of this website.

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