Attorney Referral Form

We would be happy to hear about your case or respond to any questions you may have. For more information you can also call us toll free at 888-432-4LAW. There is no charge for this review and if your case is accepted, no attorney's fee will be charged unless we are successful. The information you submit is strictly confidential.

If you believe that you or someone close to you may have a personal injury or wrongful death claim, please fill out and submit the form below for a free evaluation.

There is no charge for this evaluation

Contact Information:
 
Your Name: (required)
 Email Address: (required)
   
Street Address:
 City:
   
State:
 Zip:
   
Phone Number: (required)
Your phone and email address are required so we can reply to your inquiry.
   
Work Number:
 Date of Birth:
   
   
Injured Person Information:
 
On whose behalf are you
inquiring?
   
If you are NOT inquiring on your
own behalf, what is your relationship?
   
Is the person deceased?
Yes No
   
If deceased, the cause of death as stated on the death certificate:
   
Was there an autopsy performed?
Yes No
   
Select the practice area that
relates to your case:
   
Give a brief description about
your case:
   
I Agree to the Following:
 
Yes No
I agree that this matter may be referred to an attorney in my area who may contact me.
   
Yes No
I agree that by submitting this question, I will not be charged for the initial response. I understand that I am forming only a semi-confidential relationship.
   
Yes No

I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.

   
Yes No

I would like to receive the Shapiro & Sternlieb quarterly newsletter, The Verdict. This newsletter is your source for top-notch, valuable and current information about issues related to personal injury law. It also includes a list of current product recalls.

   
   
 
   
 

Shapiro & Sternlieb LLC
Northpoint Professional Building
176 Route 9 North, Suite 303
Englishtown, NJ 07726
732-617-8050 Phone
732-617-8060 Fax