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Potential Case Submission Form (Personal Injury and Wrongful Death)

No attorneys' fees unless you recover. Court costs, litigation expenses, and medical bills are paid from your share of the recovery. If there is no recovery, you will not be responsible for any court costs or litigation expenses, except for unpaid medical bills.

We represent people throughout Texas. If you would like our firm to review your case, call us at (214) 670-9989, or toll-free at (866) 670-9989. You may also complete the form below.

Please list the names of all persons and companies that you believe could be liable for the incident resulting in injury or death.

What caused the injury or death?

Car/truck accident Motorcycle accident Product defect Slip and fall Animal attack Accident at work Other

What is the approximate amount of medical expenses incurred as a result of the incident?

Was there a death as a result of the incident?

What type of medical treatment was given?

Please list the names of all people injured as a result of the incident.

What was the date of the incident?

Please give a complete description of the events leading to the injury or death.

Please provide the following contact information:

First Name* Last Name* Middle Initial Street Address Address (cont.) City State Texas Zip Code Work Phone Home Phone FAX E-mail* Confirm E-mail

Are you currently involved in a bankruptcy proceeding?

Yes No

What is your county of residence?

Is there any additional information which you would like to provide?

Security test. Please identify the pictures:* Identify Apple Cat Clock Dog Flower Fork Hammer Key Ship Tree Identify Apple Cat Clock Dog Flower Fork Hammer Key Ship Tree

*required