Personal Injury Case Intake Form

We would like you to complete this Initial Consultation Form in order to assist us in evaluating your case. Reviewing your Consultation Form does not mean that Wagner, Jones, Kopfman & Artenian LLP has agreed to act as your attorneys. We are agreeing only to evaluate the facts presented in your Consultation Form responses to determine whether we can assist you.

Email *

Name *

Date of Birth

Date of Injury *

Address *

City *

State *

Zip Code *

Phone Number *

Message Phone

How did the accident occur?

Describe your injuries resulting from this accident

Have you sought medical attention?
YesNo

Police Report?
YesNo

Do you have insurance?
YesNo

Your insurance agent's name:

Defendant's name:

Defendant's insurance information:

Claim Number:

Pictures?
YesNo