David Bert Havas

Todays Date:  

Name:  

Address:  

City:  

County:  

State:       Zip:  

Your preferred phone number:  

An alternate phone number:  

Fax:  

Best Time To Call:  

E-mail:  

Date of Birth:  

When did the accident or incident occur (date and time):

Where did the accident happen:

Describe Your Injuries:

Describe any medical treatment you received:

List your medical expenses (include paid and upaid bills):

Describe related medical expenses you expect to have in the future:

If you lost time from work as a result of your accident, list how much you lost so far and how much you expect in the future:

Describe your disabilities and what you can't do now that you could do before the accident:

Were you ever treated for this type of injury or problem before this accident? YES NO

Name(s) of Possible Defendant(s):

Have you discussed this with another attorney? YES NO

If so, who:

Other Comments:

"You can feel comfortable sending your information to us. We understand that your privacy is important. Therefore, when you send information to us, you can be assured none of what you send--including your name or contact information--will be made public or shared with anyone or any company."

Todays Date:  

Name:  

Address:  

City:  

County:  

State:       Zip:  

Your preferred phone number:  

An alternate phone number:  

Fax:  

Best Time To Call:  

E-mail:  

Date of Birth:  

Can you be called at work?   Yes No

Employer:  

Address:  

City:  

State:       Zip:  

Telephone No.:  

Number of Employees:  

Kind of business:  

Your Claim:  

Were you Terminated?   Yes No

If so, When:  

What was the Reason Given for Termination:

Are you a Union employee?   Yes No

Do you have an Employment contract with your employer?
Yes No

Are you a Public employee?   Yes No

Does your employer have a Policy Manual?   Yes No

Did you file a Grievance?   Yes No

If so, what is the date of filing?  

What was the outcome?

Have you filed a charge of discrimination with any agency?
Yes No

If so, with whom?  

When was it filed?  

What has happened on the charge?

Length of employment with employer you are complaining about?

What was your last salary or wages?  

Current or last position:  

Additional information you want to give us:

"You can feel comfortable sending your information to us. We understand that your privacy is important. Therefore, when you send information to us, you can be assured none of what you send--including your name or contact information--will be made public or shared with anyone or any company."