Contact information: First name:  * required Last name:  * required Email address: Telephone number:  * required Mailing address:  * required    City:  * required State:  * required Zip code:  * required Is this inquiry for you? Yes No If no, please give name and relationship: Facts about the injury: Date of the injury: (mm,dd,yyyy) Date of Birth of injured person: (mm,dd,yyyy) What City and State did the injury occur?  What kind of injury?: Facts about the injury:   Facts about the collision: Who was responsible for the collision? Did the police respond to the collision? Yes No Did anyone receive a ticket? Yes No Did the other driver have insurance? Yes No Did you have insurance? Yes No Do you have an attorney? No Yes Best way to contact you: Email address Mailing address Telephone I understand that submitting this form does not create an attorney client relationship.  I agree that no information provided on this form is confidential or time sensitive.   Yes

Important Note:  submitting this inquiry form does not mean The Gels Law Firm represents you.  In ordered to be represented by The Gels Law Firm you must be contacted by an attorney from this firm and sign an employment contract with us.