"Personal Injury Lawyer Contact"

1. Who was injured? : * . . . (select one) Me (I am the injured person.) Adult Family Member Child Family Member Other not specified
   Injured First Name? : *
   Injured Last Name? : *
   Contact (if other than injured) :

2. Injured Address? : Street *
   City / Town *   Zip code *

3. Injured Phone Number(s)? : (including area code)
   Best number to call : *   Alternate Number? :
   Best time to call : . . . . ( Select one ) Any time Days 8 AM to 5 PM Mornings 8 AM to Noon After noon to 5 PM Evenings after 5 PM to 10 PM

4. An E-mail address : *
   (enter "NONE" if you don't have one)

5. What type of injury are you inquiring about? : *   . . . . . (select one) Auto Accident Defective Product Medical Treatment Negligence Police Incident Unsafe Condition Work Accident Death Other specified below
   Other type of injury not listed above : 

6. When did the incident occur? : (month date, year) * 
   Was medical attention required? : * Yes No  
   Was an accident or incident report made? : * Yes No

7. Where did the incident occur? : *  . . . . (select all that apply) At Home At Work Medical Facility On Private Property On Public Property Within a Structure Outside Within a vehicle Other location listed below (Use the "Ctrl Key" with multiple selections)
   Other location not listed above : 

8. Please briefly describe How the injury / incident occurred : *
   

9. Briefly describe Why you think the injury / incident occurred : *

10. Additional information or questions you would like reviewed by a personal injury attorney. :
    

To send this form to an Irom Law Personal Injury Lawyer for review, click the Submit Button below. We will review your inquiry and will respond to you as quickly as possible. Remember, the fields with a RED * are required. If for any reason you are uncomfortable with, or have difficulty, submitting this form, please feel free to contact us by phone at 800-304-0220.  All information provided remains confidential.