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One Midtown Plaza
1360 Peachtree Street, Suite 910
Atlanta, Georgia 30309
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Toll Free: 877.778.7944
Phone: 404.253.7860
Fax: 404.253.7875

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Injured Person Information: Whom are you inquiring on behalf of? If you are NOT inquiring on your own behalf, what is your relationship? Injured Person's Name Injured Person's Age Injured Person's Occupation

Matter Information: Date of Incident: (mm/dd/yyyy) Where did the Incident Occur (City and/or County & State)? Nature of Legal Matter Name of Adverse Parties / Who Caused The Harm? Damages that were sufferred: Has a law suit already been filed? Yes No What else should we know to help you?

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