Questionnaire

For a free evaluation of your California personal injury claim, please fill out the following form completely and submit it to us. We try to respond to all submissions by telephone, usually the following day. Please be aware that in submitting this form you are not retaining legal services from the Law Offices of Lombardi and Perry, LLC. The items listed in this form are the minimum facts needed for an attorney to begin to evaluate your claim. If you do decide to retain our services, we can get a jumpstart on formulating a plan of attack, putting together a powerful case so that by the time you meet with us, we are already well ahead of the game.

Name:
Address:
City, State, Zip:
Contact Phone:
Email:
Type of Employment:
Your Insurance Carrier:
Negligent Party's Insurance Carrier:
Your Private Health Insurance:
Any Other Type of Medical Benefits:
Date of Incident:
Time of Incident:
Place of Incident:
Investigated by: State Patrol Sheriff Local Police Other Agency None
FACTS: In your own words, describe how the incident occurred.
What injuries resulted from the incident, who was injured, and how have the injuries progressed?:
What medical treatment has taken place?
a Medical Expenses to Date:	a
Time Loss from Work to Date:
Property Damage:
Transportation Costs, Car Rental, etc:
Any Other Losses: