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  Case Evaluation
Your Name:    *
Street or PO Box Address  
City
State
Zip Code
Home Phone Number   *
Work Phone Number
Cellular Phone Number
Best Time to Contact You
Email Address   *
Secondary Email Address
Name of Your Child
Is your child male or female?

Male Female
Age of your Child as of today's date   *
Age of your child at the time of the accident Accident   *
Date of Accident or Incident   *
Did your child go to the Hospital? If so, please provide the name of the Hospital
Is your child deceased due to injuries sustained in this accident / event?

Yes No
Did you contact the Police Department or other law enforcement agencies? (if appropriate)

Physical Place of Accident
Business or Private Residence
Street Address
City
State
Zip Code
Have You Been Contacted by An Insurance Adjuster?

Yes No
If so, please list the adjuster's name, address and phone number
Have You filed Bankruptcy or were in a Bankruptcy at the Time of the Accident or Event?

Yes No
a) If so, list the name of the Court
b) your case number
c) the name of Your bankruptcy Attorney
d) the address of your bankruptcy attorney
e) the phone number of your bankruptcy attorney
Describe in DETAIL everything that happened from the date of the injury to present.
Describe the specific medical injuries suffered by your child or children.
Do you know the manufacturer of the product (if a product)

Yes No
Have you saved, stored or kept all the objects, items or materials that injured your child?

Yes No
Please describe in detail what you have in your possession.
Insert Code :

By submitting this evaluation you are asking for Attorney Randal S. Ford to review your case for possible litigation. You have not employed Randal S. Ford by means of contacting him through this website. An employment relationship will only be initiated upon the signing of an employment contract. By your submission you are agreeing to be contacted by Randal S. Ford by email, mail or telephone to discuss the case or matter that you have presented below. You understand that your case is governed by your state's Statute of Limitations and that Randal S. Ford is not responsible for any damages that may accrue should you fail to file your lawsuit during that time. It can take several weeks to a few months to obtain all the records necessary to evaluate your potential case. Attorneys obtain all medical documentation, accident reports, and other documentation necessary to make a determination to engage in an employment contract with you and your family due to the expense and risk of litigation.

 

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