Please fill the form out as completely as possible. When we have evaluated the case information we will contact you. Using this form will help us to expedite your case.

Mr.    Mrs.    Ms.                                    Name:                                       Age: Marital Status: Married   Single Divorced   Separated Widowed                   Spouse's Name: Address: City: County: State: Zip: Home Phone: Work Phone: Other Phone: E-Mail Address: Employer: Employer Address: Date and Time of Accident: Location of Accident: Name of Adverse Party: Were tickets issued? Yes       No If Yes, who was charged with the accident? What were your injuries? Hosptial Name/Dates, if applicable? Your Insurance Company: Adverse Insurance Company: Is another attorney involved? Please give a description of the accident: After you have checked the information given above, please click the Submit button.                       Do NOT talk to the other side's insurance company before consulting with us. You are NOT legally required to talk to them. Do NOT sign anything.

CLICK  HERE
For an informative brochure to keep
in your car.

LedfordLaw.com • Ormond Beach, Florida • 386-672-6611
© 2002, James W. Ledford. All rights reserved.
Privacy Statement.