Free Injury Case Evaluation Form

Please take a moment to complete this form. Provide as much information as possible. This form is intended to assist us with a preliminary evaluation of your case. When you have completed the form please click the "Submit" button and we will contact you to discuss your case as soon as we have reviewed your information.

Note: fields with a * are required.

YOUR CONTACT INFORMATION

* First and Last Name:

* Address:

* City:

* State:

* Zip Code:

* Home Telephone:

- -

Fax Number:

- -

* Email Address:

YOUR INJURY INFORMATION

* Date of Incident:
Is there a police report?
If yes, do you have a copy?
Type of Accident:
How did the Injury Happen:
Describe Your Injuries
Other Comments:

**PLEASE DO NOT GIVE A WRITTEN OR RECORDED STATEMENT
TO THE INSURANCE COMPANY!**

Stawicki & Maples
3353 Bradshaw Road, Suite 115
Sacramento, CA 95827

Tel: (916) 363-2889
Fax: (916) 363-2019

info@stawickiandmaples.com

BRANCH NUMBERS:

Solano Couty:
(707) 434-9771

Amador, Calaveras, Tuolumne & San Joaquin Counties:
(209) 632-1684

Contra Costa County:
(925) 692-1155

Sutter, Yuba, Yolo, Placer & El Dorado Counties:
(530) 741-1050

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