Seattle Personal Injury Lawyer

Paglialunga & Harris, PS | Winning Justice

Personal Injury, Accident & Wrongful Death Lawyers Seattle, Washington

Personal Injury | Wrongful Death | Accident Claims

FREE Initial Consultation 1-888-604-3438

Case Evaluation

If you believe that you or a loved one has suffered from any Accident or Injury, please fill out the form below. There is no charge for this evaluation.

* Required Fields.

*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 / 10005-1009)

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

Case Information:

Date of Accident or Injury:

Occupation :

Name and Address of Employer:

Describe Related Injury:

Does Injury Prevent Working? Yes No

If yes, when did you stop working:

Approximate Money Lost Due to Injury:

Other Information:

Yes No - I agree that this matter may be referred to an attorney in my area who may contact me.

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.

By Clicking the appropriate box below, I agree to:

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