R.F. Wittmeyer - A Personal Injury Lawyer - Case Information Worksheet

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(847) 577-1123
rfw@injurylawattys.com

R. F. Wittmeyer, Ltd. - Attorneys at Law - A personal injury lawyer specializing in car accidents, plane crashes and wrongful death cases involving victims with brain, head or back injury.

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R.F. Wittmeyer, LTD. - Preliminary Fact Finder

If you cannot answer a question, or if it does not apply to you, leave blank.
(Call us directly if you need help with this form (800) 709-1123 or simply e-mail us your info.)

Victim's Information
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Telephone:
Work Telephone:
Other Phone: Specify -	Cell Phone Pager Fax
E-Mail:

Your Information (if different)
Name:
Relationship (to Victim)
Home Telephone:
Work Telephone:
Other Phone: Specify -	Cell Phone Pager Fax
E-Mail:

Who do you want us to contact? You directly The victim Other
Other Contact Name:
Other Phone or Email:
How to make contact? E-Mail Telephone U.S Mail Date of Incident:
Type of injury / accident?
Vehicle	Medical Malpractice
Other Transportation	Construction Site / Industrial
Defective Product	Work Related
Slip / Trip / Fall	Other
Describe the Incident: Describe the Injuries: Amount of Medical Bills (to date): $ Describe Medical Treatments: Are you currently represented by an attorney? Yes No In what state did the accident, injury or death occur? Was a Citation/Ticket issued or arrest made: List the Responsible Parties -- 1st Party --
First Name:
Last Name:
Insurance Company:
-- 2nd Party --
First Name:
Last Name:
Insurance Company:
How Did You Find Us?
Who referred you?
What search engine(s)?
What keywords did you use to search for a lawyer?
What about our website prompted you to contact our law firm?
Any Other Information: This form creates and sends information with the contents of these fields. It won't send mail unless the email address is valid.

Free Consultations
You may contact us by telephone at (800) 709-1123
or by e-mail at rfw@injurylawattys.com

R. F. Wittmeyer, Ltd.
1635 N. Arlington Heights Rd., Suite 104
Arlington Heights, Illinois 60004
(847) 577-1123
Fax (847) 577-2827
E-mail: rfw@injurylawattys.com

Attorney Ron Wittmeyer, as a former claims adjuster is committed to excellence in legal representation.
We are dedicated to prosecuting each client's case that we accept to the fullest extent of the law.
Remember, your attorney works for you (the client), not vice versa.

Personal injury lawyers for car accident, wrongful death, spinal cord injury,
brain or head injury and auto accident cases.

Feb	MAY	Jun
	11
2004	2006	2007