1-800-I-GOT-HIT - The Law Office of Martin E. Lazzaro, Online Evauation

Lazzaro Law Center
7240 McKnight Road
Pittsburgh, PA 15237

Online Evaluation Questionnaire
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COMPLETE OUR FREE ON-LINE QUESTIONNAIRE for us to review.

By answering a few simple questions about your automobile accident, we will review this information and respond accordingly. This is a free, no obligation, evaluation and the information you submit will be reviewed during office hours. You will be contacted as soon as possible to discuss your potential claim.

If you prefer, you may call our office, toll free, at 1-800-I-GOT-HIT.

* Questions in red are required fields. Please note: This form is being sent via secure server.

Your Contact Information

First Name:
Last Name:
Street Address:
City and State:
Zip/Postal Code:
Phone Number:	--
Work Number:	--
Email Address:

Injured Person Information

For whom are you inquiring?
Name of injured person (if different than above):
Age of injured person:
Does the injured person currently have an attorney?	yes no

Accident Details

City and state of accident:
Date of the accident:

Please briefly describe the accident:

Pennsylvania residents only: What is the tort option on your auto insurance?	full tort	limited tort
Was anyone involved in the accident arrested for DUI?	yes	no
Were you in a commercial vehicle at the time of the accident?	yes	no

Please describe your injuries:
Have you received medical treatment for your injuries?	yes	no
Have you lost pay as a result of your injuries?	yes	no

Please list any other questions, comments or concerns you may have.

We appreciate your time in completing the above-questionnaire and giving us the opportunity to evaluate your claim.

Sometimes it is necessary to gather additional information over the telephone to adequately evaluate your claim and that is why we ask for your telephone number. Please provide a number where you can be reached during business hours.

The information contained in this form and the submission thereof is not intended to create an attorney/client relationship between The Law Office of Martin E. Lazzaro and the sender.
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