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Submit A Free Case Review

Please fill out the following for a free case review. The information submitted will be accorded the utmost confidentiality. This information is necessary in order to do a conflict of interest check before responding to you. If you prefer, you may contact us at (813) 224-9100 or toll free (877) 768-9100.

Please provide the following information for the person in need of assistance. Fields with (*) are required.

*Full Name

*Date of Birth

*Street Address

*City, State, Zip

E-Mail

*Home Phone

Other Phone

Marital Status
Married
Single
Separated
Divorced
Widowed

Name of Spouse, If Any

Occupation

Highest Level of Education Attained
High School
Some College
4 Year Degree
Advanced Degree

Please provide a brief overview of the legal matter you need assistance with.

Injury Cases

If you need assistance with an injury matter (including wrongful death claims, product liability claims and malpractice claims) please submit the following information as well.

City and State in which you were injured.

Name(s) of the person(s) who you allege caused you injury, and their addresses, if known.

Please describe your injuries.

Please describe any treatment you have had so far.

Are you still being treated for your injuries?
Yes
No

If yes, what kind of treatment are you now getting and/or do you anticipate in the future?

What is the approximate amount of your medical bills thus far?

Have you been forced to miss work due to your injuries?
Yes
No

If so, how much in lost wages and/or benefits have you sustained?

Have you been contacted by any insurance company regarding your injuries?
Yes
No

If so, what is the name and address of the insurance company and adjuster(s) you have talked to?

Are you currently represented by another lawyer?
Yes
No

If so, please give us the attorney’s name, address and phone number.

If You Are Not The Injured Party

If you have filled this information out for someone else, and are not the person in need of assistance, please answer the following:

Full Name

Street Address

City, State, Zip

E-Mail

Home Phone

Please describe your relationship to the person in need of assistance (e.g. parent, spouse, friend)

For Parents or Guardians

If the person in need of assistance is not a minor or disabled, we will need to communicate directly with that person regarding our review, in order to maintain attorney/client confidentiality. If the person in need of assistance is a minor or is a disabled adult with an appointed guardian we will need to communicate with that parent or guardian. With this in mind:

*Who is the person to be contacted after we have completed our review?

*What is the best time to contact that person?

*What is the best way to contact that person? (e.g., e-mail, phone, letter)

After the information is complete, please press the submit button. We will review the information and contact you as soon as we have done a conflict of interest check.

We will try to respond to you as soon as possible regarding your inquiry. Thank you for the information you are able to provide because it will help us evaluate your claim. Please be aware that a telephone inquiry, an e-mail, or other communication to Bales Weinstein does not create an attorney-client relationship. Nor does contacting us mean you have automatically become a member of a class action, whether the class has been certified or not. This firm cannot serve as your counsel in any matter unless both you and a representative of our firm sign an agreement confirming in writing our attorney-client relationship. You should also be aware that the statutes of limitation (the deadlines imposed by law within which you must bring a lawsuit) may severely limit the time remaining for you to file any claims you may have and, ultimately, could bar those claims. Accordingly, you should take appropriate steps to protect your legal rights. By submitting this evaluation form, you are agreeing to the above.

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Web Site Disclaimer: The Florida personal injury, worker's compensation, medical malpractice, nursing home abuse, product liability, mass tort drug litigation, consumer fraud, business litigation, environmental litigation, social security law, and/or other legal information offered herein by Tampa Florida Personal Injury Attorneys is not formal legal advice nor the formation of an attorney client relationship.

Copyright © 2005 Bales Weinstein Attorneys at Law - Tampa personal injury lawyers, worker's compensation attorneys, medical malpractice lawyers, nursing home abuse attorneys, product liability lawyers, mass tort drug litigation attorneys, consumer fraud lawyers, business litigation attorneys, environmental litigation lawyers, social security law attorneys serving Florida. All rights reserved.