Malik Shakur Attorney-at-Law

Case Evaluation

Personal Injury Form | Traffic/DUI/Criminal Form | Family/Domestic/Other Form

Not sure if you need a lawyer? Don’t have the time to schedule an appointment this week? Not a problem. Just fill out our Online Case Evaluation Form. We will carefully review the information you provide, and contact you with a professional opinion. It’s free, it’s fast and it’s a start in the right direction.

Remember: There is no charge for this consultation and no obligation to use our services.

Personal Injury Evaluation Form

Review your information carefully before you submit it. If you need to start over, press the "Clear Form" button below. Otherwise, click the "Submit Form" button. Please click your selection only once to avoid multiple submissions.

General Contact Information:

Your Name:

Injured Person's Name (if different from above)

Whom should we contact:

   

Please supply the following information for the person we should contact regarding this claim:

Street Address:

City:

State:

Zip:

E-mail Address:

Best time to contact you:

Home Number:

eg. 555-555-5555

Work Number:

eg. 555-555-5555

Mobile Number:

eg. 555-555-5555

Fax Number:

eg. 555-555-5555

Type of Accident:

Legal Issues:

Have you contacted any other lawyer about your potential claim?

If Yes, did the lawyer agree to represent you?

Are you still being represented by the lawyer?

General Incident Information:

On what date were you injured?:

eg. 6/15/2003

In what city and state did the injury occur?

Did the injury occur on your employer's premises?

Please briefly explain the incident that caused your injury:

Please briefly describe your injuries:

Do you believe that any of your injuries are permanent?

Do you have a permanent, visible scar on your face, head, or neck?

Employment and Earnings:

Who is your employer?

What is your occupation?

Have you lost any earnings due to injury?

Are you still off of work due to this injury?

Medical Information:

When did you first receive medical treatment?

eg. 6/15/2003

Who chose the doctor?

What is the doctor's name?

What is the doctor's specialty?

Has any doctor said.... (check all that apply)

You are not able to work?
Your injury is work-related?
You can return to full-duty work?
You can return to light-duty work?

Additional Information:

How did you find our website?

Search Engine
Television Ad
Radio Ad
Newspaper Ad
Referred by a Friend
Other:

Are there any other questions you wish to have answered?

 

Disclaimer: Submitting this form in no way obligates Malik Shakur, Attorney-at-Law, or any of its associates or affiliates to provide legal representation to the above listed party. The information contained herein is for evaluation purposes only, and NO legal representation is guaranteed until a written contract is signed between Malik Shakur, Attorney-at-Law and the above listed party. Further, Malik Shakur, Attorney-at-Law has the right to deny or refuse legal representation to the above listed party at their sole discretion.