Name:
Address:
City:
State:	Zip:
Phone:	Email:
Please contact me by Phone Email in the Morning Afternoon Evening

 

Injured Person Information:

Whom are you inquiring on behalf of?	Self Other
If you are not inquiring on your own behalf, what is your relationship?
Is this person deceased?	No Yes
If yes, what is the cause of death as stated on the death certificate:

 

Case Information:

Date Purchased / Received:
Product Name:
How is the product defective:

 

Other Information:

Please list any other information or questions.

I agree that the above does not constitute a request for legal advice and I am not forming an attorney-client relationship by submitting this questionnaire. I understand that I may retain an attorney only by entering into a separate fee agreement. As such, I will not be charged for the initial response to this questionnaire and I understand that the response I receive should be considered only as general information, and not as legal advice. I also understand that the law for each state may vary and that this matter may be referred to an attorney in my area who may contact me.