Information Form

When you or a loved one is injured the best course of action is to contact us by phone, even after business hours, as we regularly monitor our voice messages.

But we understand that sometimes calling can be difficult so we provide this feedback form to make it easier for you to tell us about your situation.

*This form requires only a name, phone number, and email. We would like to repsond to your inquiry as quickly as possible.
Name  
Phone:  
Email:  
     
Optional Information:
2nd Phone:  
Address 1  
Address 2  
City  
State  
ZIP  
Sex   Female Male
Marital Status  
Occupation  
Incident Date  
Time of Incident  
Description of Incident  
Eyewitness Name  
Eyewitness Phone Number  
Doctor's Name  
Doctor's Address  
Doctor's Phone Number  
Hospital's Name  
Hospital's Address  
Hospital's Phone Number  

Disclaimer: The Colleran Firm only provides legal advice after it has entered into an attorney-client relationship, which this website specifically does not create. Only after having entered into a written, signed agreement with The Colleran Firm will an attorney-client relationship have been created. It is imperative that any action taken be done on the advice of counsel. Because every case is different, the descriptions of awards and cases previously handled are not meant to be a guarantee of success.