Does Your Attorney Care?

Do I Have a Case?

Do I Have A Case?

General Intake Form

* = Required field

*Name:

*Address:

*City:

*State:

Zip:

*Phone:

Home:

Business:

Cell:

*E-mail Address:

Preferred Method of Contact:

Do you have an attorney?
Yes No

Name of Attorney?

*Date of Injury / Loss / Death

Who was Injured?

Age of Injured:

Your relationship to Injured:

If other please describe:

What area of law does your situation involve (if known)?

*Address (include county) where incident occurred:

*What happened (include relevant dates):

People and organizations/companies involved in the incident:

What documents do you have that could help explain the situation?

Doctors/Medical Providers Involved:

Amount of Medical Bills:

Names of your health, accident or disability insurance carriers:

Have you been paid benefits arising out of your injury?
Yes No

If yes, who paid benefits to you?

Defendant(s) Insurance:

How has this situation impacted the injured person?

What would you like to happen to resolve this issue (preferred outcome)?

Notice:

Responding to this Legal Issue Inquiry allows The Law Offices of Randall D. Moore to begin evaluation of your claim. It does not constitute an attorney/client relationship. We appreciate the opportunity to evaluate your inquiry and respond back to you regarding our decision whether we can represent you in this matter.

 

Located in Fort Worth, the personal injury lawyers of The Law Offices of Randall D. Moore, PLLC represent clients throughout North Texas, including the cities of Cleburne, Decatur, Denton, Weatherford, Arlington, Stephenville, and residents of Parker County, Johnson County, Wise County, Dallas County, and Tarrant County.