Free Initial Case Evaluation

Our free immediate case evaluation form is designed to help individuals determine if they have a personal injury case. Please fill in as many details about your potential case as possible. Our Milwaukee personal injury attorneys will review your situation and will contact you to discuss your legal options. If you need immediate legal assistance, please call our law office at (414) 224-0400 or fax us at (414) 224-0280.

Personal Information
Last Name: * First Name: * Middle Initial:
Address: * Email: *
City: * State: * Zip Code: *
Phone: * Cell Phone: Work Phone:
Business Address: Business City, State, and Zip Code:

Accident / Injury Information
Please select all that apply
Motor Vehicle Accident
Automobile
Truck
Motorcycle
Pedestrian
Bicycle
Other:
Personal Injury
Slip and Fall
Product Injury
Workplace Injury
Burn Injury
Nursing Home
Wrongful Death
Dog Bites
Mesothelioma
Medical Malpractice
Vaccine Injury
Other:
Other Legal Issues
Workers' Compensation
Civil Rights
Police Brutality
Other:
Motor Vehicle Accident Details
Yes No  
Police Called
Citation Issued
Ambulance Dispatched
Accident Report
Insurance
Pictures of the Scene

How did you find us?
Attorney Referral
Personal Referral
Yellow Pages
Google
Website
Better Business Bureau
Other:
Other Important Information
Yes No  
Have you consulted another lawyer(s) on this matter?
    If yes, how long ago?
Are you consulting Samster, Konkel & Safran on your own behalf or for someone else?

If your answer to the previous question is yes, please check
 all that apply.

He or she is a minor I am his / her legal guardian
We are related I am his/ her power of attorney

If you are related, what is the extent of your relationship?
 
Incident Information

Date of Incident: * Location of Incident: *

Extent of Injury: *


Extent of Property Damage: *

Briefly Describe Nature of Incident (including time of day, road and weather conditions): *


Disclaimer:
By submitting this free case evaluation form, you have not retained Samster, Konkel & Safran, S.C. as legal counsel. The information you submitted does not create an attorney-client relationship. Do not submit any confidential information to us until an attorney-client relationship has been established.

I have had an opportunity to review and understand this disclaimer.

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