FOR CIVIL RIGHTS AND OTHER INCIDENT CLAIMS:

THANK YOU FOR YOUR CONSIDERATION OF OUR LEGAL SERVICES. FIRST, MAY WE REQUEST THE FOLLOWING INFORMATION. PLEASE TYPE IN ALL APPLICABLE BLANK AREAS AND CLICK SEND AT THE COMPLETION OF PAGE.

HOW DID YOU HEAR ABOUT US?

 

ARE YOU SUBMITTING THIS INFORMATION  ON YOUR OWN BEHALF 
OR FOR SOMEONE ELSE?   

WHAT TYPE OF ISSUE OR CLAIM CAN WE HELP YOU WITH? ("x" after category)

MARITIME ;  PERSONAL INJURY ;  DEATH ;  CIVIL RIGHTS  ;

OTHER [describe]

DATE INCIDENT [first] HAPPENED or DATE BY WHICH FUTURE 
ACTION TO BE TAKEN  Month Date Year

Please Enter Your Responses ["Yes" or "No" or Requested Details] 
Following Each Applicable Question

1. Did the incident arise at or on account of gainful employment?

Yes or No

2. Did wrong come about through the conduct of a government employee?

Yes or No

1. IF SO, specify federal or other government agency or department:

 

3. Were there any witnesses to the conduct whom you think would give a positive statement?

 

 

4. Were any complaints of wrongful treatment made?

 

5. Were any reports made? Yes or No

SET FORTH THE FACTS OF THE CLAIM, including dates and bills incurred (approximate total sum to date) and any other monetary losses (approximate to date). 

THIS SPACE EXPANDS

* the above information is necessary for a response.