Tell Us About Your Case

GraceHollis LLP agrees to handle only selective cases of significant personal injuries. GraceHollis does not accept medical malpractice cases against physicians. With this understanding, you are invited to complete this form and send it to us electronically for review. Remember, as stated in the Terms of Use, your use of this Web site does not create an attorney-client relationship. Thanks for considering GraceHollis for your personal injury legal needs.

First Name *
Last Name *
Address *
City *
State *	Zip *
Day Telephone
Evening Telephone
Email *
Type of Injury
I am seeking legal assistance to:

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The injured party was:	Driver of an automobile Passenger of an automobile Pedestrian
Date of accident
Place of accident
Number of vehicles involved in accident Describe how the accident occurred. Please do not identify other parties by name. Did anyone witness the accident? Yes No Was a police report filed? Yes No Who was at fault in the police report? I was Other driver Inconclusive Nature of property damages No damage Major structural damage to vehicle Minor damage to vehicle Vehicle is totaled and will not be repaired Other Nature of personal injuries Anxiety Back pain Broken bones Headaches Impaired vision Loss of feeling in part of body Loss of limb Memory loss Neck pain Rehabilitation therapy required Shoulder pain Surgery required Other Have you suffered from a prior injury to the same part of the body? Yes, on this date No Date you first received medical care for injury Status of medical treatment No treatment yet Currently in treatment Stopped treatment but need to restart Treatment completed Medical practitioners visited for injury Medical doctor Surgeon Chiropractor Costs of medical treatment to-date: Have you missed work due to the injury? Yes No
Amount of work income lost to-date
Gross annual income
Occupation
Age
Have any documents been filed with the court? Yes No Where do you hear about our law firm? I understand that I have not hired GraceHollis LLP and the act of submitting this questionnaire does not alone create an attorney-client relationship. I agree to follow and be bound by the Terms of Use.

am seeking legal assistance to:	Make a claim for an injury Defend against a claim
Date of Injury
Place of Injury
Describe how the incident occurred. Please do not identify other parties by name. <?=getFieldValue('PI description');?> Did anyone witness the injury? Yes No Was an investigation conducted? (For example, police report) Yes No Nature of injuries Anxiety Back pain Broken bones Headaches Impaired vision Loss of feeling in part of body Loss of limb Memory loss Neck pain Rehabilitation therapy required Shoulder pain Surgery required Other Have you suffered from a prior injury to the same part of the body? Yes, on this date No Date you first received medical care for injury Status of medical treatment No treatment yet Currently in treatment Stopped treatment but need to restart Treatment completed Medical practitioners visited for injury Medical doctor Surgeon Chiropractor Costs of medical treatment to-date: Have you missed work due to the injury? Yes No
Amount of work income lost to-date
Gross annual income
Occupation
Age
Have any documents been filed with the court? Yes No Where do you hear about our law firm? I understand that I have not hired GraceHollis LLP and the act of submitting this questionnaire does not alone create an attorney-client relationship. I agree to follow and be bound by the Terms of Use.

I am seeking legal assistance to:	Make a claim Defend against a claim
Relationship to decedent	Spouse or registered domestic partner Parent Child Other
Date of Incident
Place of Incident
Date decedent died
Describe how the incident occurred. Please do not identify other parties by name. Costs of medical treatment(s) Was decedent married at time of death? Yes No Did decedent have any minor children at time of death? Yes No Was decedent employed at time of death? Yes No
Gross annual income
Occupation
Age
Have any documents been filed with the court? Yes No Where do you hear about our law firm? I understand that I have not hired GraceHollis LLP and the act of submitting this questionnaire does not alone create an attorney-client relationship. I agree to follow and be bound by the Terms of Use.