PERSONAL INJURY INQUIRY

If you or a loved one has been injured due to the negligence of someone else, please provide the following information so we may review your matter and schedule an in-person consultation.

Submission of information through this form is for information purposes only, and to allow us to briefly review your potential case. Use of this form does not establish an engagement on your matter, and does not create an attorney-client relationship. Whether or not we accept your case, all information submitted is confidential and will never be shared outside the firm. If we accept your case, you will be provided with a formal "Letter of Engagement" establishing the rights and obligations associated with your case.

Name *
Name
Address *
Address
Phone
Phone
Date of Accident/Injury *
Date of Accident/Injury
Please briefly summarize how you were injured, by whom you were injured (if you know), where the accident took place, the nature and extent of your injuries, the names of anyone that was injured at the same time as you, the names of any witnesses, and any other information you believe to be relevant to your case.
Have You Seen a Doctor? *
Disclaimer *
I acknowledge that submitting this form does not create an attorney-client relationship, does not create or constitute a claim against any entity, and that I wish for a representative of Breslin Law Group to contact me by phone or email to discuss this matter further.