Since 1977... Bringing Justice and Compensation to our Clients

Call Us Now
877-FL-Injury

Personal Injury Case Evaluation Form

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Who was injured?

If "Other," please describe:

Injured person's name (if different from above):

Address:

City:

State:

Zip:

E-mail address:

Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

When did the injury occur?

Where did the injury occur?

This location was the injured person's

If "Workplace," did the injury occur as a result of employment activities?
Yes   No 

If "Other," was this a road accident?
Yes   No 

If no, did the injury occur on another's property?
Yes   No 

If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?
Yes   No 

If yes, what are the witnesses names/contact information?

Were others involved or injured at the same time?
Yes   No 

If yes, what are their names/contact information?

Was there a police report?
Yes   No 

Did the injured person receive medical treatment?
Yes   No 

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
Yes   No 

Was the injured person killed as a result of the accident?
Yes   No 

If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

Where did you hear about this website?

The contents of this contact form are provided by and are the responsibility of the person posting the email communication. Your email will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. You acknowledge that any reliance on material in email communications is at your own risk.

Florida Personal Injury Office Locations

Main Office

Orlando Personal Injury Office:
3117 Edgewater Dr.
Orlando, FL 32804
Phone: 407-425-2000
Toll Free: 877-FL-INJURY
                 (877-354-6587)
Fax: 407-843-8274

Seminole County

Lake Mary Office:
1001 Heathrow Park Lane
Suite 4001
Lake Mary, FL 32746
Phone: 407-487-4408

Osceola County

Kissimmee Office:
17 S. Orlando Ave.
Kissimmee, FL 34741
Phone: 407-966-4408

Volusia County

Daytona Beach Office:
1301 Beville Rd., Suite 8
Daytona Beach, FL 32119
Phone: 386-243-4994

DeBary Office:
465 Summerhaven Drive, Suite C
DeBary, FL 32713
Phone: 386-320-3911

Deland Office:
Downtown Executive Center
120 South Woodland Blvd.
Deland, FL 32720
Phone: 386-206-1264

Citrus County

Inverness Office:
110 North Apopka Ave.
Inverness, FL 34453
Phone: 352-205-4341

Polk County

Lakeland Office:
1102 S. Florida Ave., Suite 104
Lakeland, FL 33803
Phone: 863-968-7551

Winter Haven Office:
325 Avenue A, N.W.
Winter Haven, FL 33881
Phone: 863-968-7173

Hillsborough County

Tampa Office:
100 S. Edison St. Suite D
Tampa, FL 33606
Phone: 813-355-9772

Marion-Sumter Counties

The Villages Office:
3420 U.S. Hwy. 27/441
Fruitland Park, FL 34731
Phone: 352-419-0825

Lake County

Mt. Dora Office:
602 East 5th Ave.
Mt. Dora, FL 32757
Phone: 352-436-4696

Clermont Office:
900 W. Highway 50
Clermont, FL 34711
Phone: 352-503-4674

Brevard County

Titusville Office:
506 S. Palm Ave.
Titusville, FL 32780
Phone: 321-222-7300

Cocoa Office:
96 Willard Street
Suite 206,
Cocoa, FL 32922
Phone: 321-757-1373