Please fill in as much as possible. Information must be supplied for
highlighted items (identified by *).
1. Means of Contact
2. Please give the date of the event that caused your injuries and the location (city, county and
state). Be accurate because choice of venue and statute of limitations are involved.
- Date (MM/DD/YY)*
- City*
- State*
- Zip*
- County
3. Please describe the event. Be specific as to how the event transpired, who was at fault for it and why, whether any person witnessed the event and whether the police investigated.
4. Have you decided to retain an attorney? State why or why not.
5. Please give a
full description of your injuries, with details.
6. Please
give a full description of the medical treatment received thus
far (e.g., physical therapy, medical doctor, medical specialist,
etc.) and the estimated charge to date.
7. Have you finished treating? If not, when do you
or your doctors estimate that treatment will be over?
8. Do you or your
doctors believe that you have any permanent injuries or limitations? If so,
please describe all permanent injuries and limitations.
9. Does the
party-to-blame have insurance? If so, identify the insurance carrier.
10. Do
you have insurance that may cover your loss? If so, state the carrier, type of
insurance (e.g. auto, homeowners, etc.) and the amount of your coverage.
11. What question do you want answered, or what additional
information do you want from me? Please be specific.
Thank you.
Melvin
Dubinsky · 170 Broadway · New York, NY 10038
Tel. 212-233-4354 · Fax 212-233-1150
