Contact & Intake Form Submit this intake form for an immediate free case evaluation. Contact & Intake Form Step 1 of 3 - Step 1 33% Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email Preferred mode of communicationEmailTelephonePostal mail Referred by*How did you hear about the Hassell Law Group?Former or current law firm clientFriend / Family / Co-workerAnother attorneyYelp!GoogleWhat do you want to discuss with an attorney?*Personal Injury / AccidentEmployment Law CaseGeneral InquiryPlease tell us about your potential case.Facts of the Accident / LiabilityDate and time of accidentAccident LocationCity, Streets, etcAre there any witnesses?YesNoIf so, do you have their contact information?YesNoIs there a Police Report?YesNoIs there a dispute as to who is at fault for the accident?YesNoWho is your auto insurance carrier?Who is the other party's auto or liability insurance carrier?Who is your health insurance company?Loss of EarningsExplain if you missed work due to the accidentEmployerJob title/descriptionDid a medical provider tell you to take time off from work?YesNoPlease explain.Facts Supporting Your Claim(s)Date and time of incidentLocation Where Any Incidents Occurred (City, State, etc.)Are there any witnessesYesNoIf so, do you have their contact information?YesNoNumber of employees employed by this employerDid you complain about the incident(s)?YesNoIf so, to whom, and when?Have you filed a formal complaint with the DFEH or the EEOC?YesNoIf so, when?Describe what happened and facts that you think may support a legal claim against the employer.Any other details of your situationWhat is/was your job title at the company?What is/was your pay rate? Property DamageDescribe the damage to your property (if applicable)Cost of the damage or repairs to your propertyHave you already been paid for your property damage?Treatment / InjuriesDescribe your injuriesDid you complain of pain at scene of the accident?To whom?How soon were you treated for your injuries after the accident?Where and by whom?Do you intend to get further medical care for you injuries? Please explain.List any pre-existing injuries to the same parts of your body as were injured in this accident.Have you been involved in any other accidents where you were injured? Please explain.How much are your medical costs to date? (If you know.)MiscellaneousPlease tell us anything else you think we should know about your case to better evaluate itCaptchaPhoneThis field is for validation purposes and should be left unchanged.