Name:

Address:

City:

State:

Zip:

Phone Day:

e.g. 555-555-5555

Night:

e.g. 555-555-5555

E-Mail:

Often we are contacted by someone other than the person in need of help. For example, sometimes the injured family member cannot respond or has died. Please provide the following information on behalf of the person who needs assistance.

The Information below is about me:

Age of the injured person:

What is the date that you were injured or the date you first learned you or your family member or friend were injured?

Date injury occurred:

Where did the injury happen?

City:

State:

How can we help you? Please provide a brief overview of why you believe you or your family member has a case

What damages and/or injuries were suffered?

Who or what caused the injury?

Has anyone already filed a suit?

If you have any problems filling out this form please call us. We would be very happy to help you over the phone. When this form is complete, please press the submit button below to send your inormation to the Mulligan Law Firm. Your information will be kept strictly confidential.