Attorney Case Referral Form

 

Thank you for your interest in Brayton Purcell. We are interested in accepting referrals and would be pleased to describe our experience and expertise. Please take a few minutes of your time to fill out this form.

Your Name or Law Firm:
Phone Number:
E–mail Address: (Privacy Policy)
Best Time to Contact/ Method to Contact:
Name of Injured Party:
Date of Birth or Age of Injured Party:
Type of Case:	Please choose one... Asbestos Benzene Beryllium Class Actions Defective Medical Devices Elder Abuse HMOs Lead Paint Maritime Claims Medical Drugs Medical Malpractice Mortuary Malpractice MTBE Personal Injury Railroad Tobacco Toxic Mold Welding Rods Workers’ Compensation Workplace Harassment Other If Other:
Is this a wrongful death case? Yes No If “yes,” please provide the date of death of decedent.
Diagnosis or Injury: If injured party was diagnosed, when and how if known: If not an asbestos or other type of toxic exposure case, when and how did the injury occur if known. (If it is an asbestos or other type of toxic exposure case, please fill out No. 4 Exposure Summary below.)
Smoking history if applicable:
If an asbestos case or other type of toxic exposure, please give a brief exposure summary:
Is the injured party married? Yes No Dose the injured party have dependents? Yes No
If this is a work–related injury, are you referring the injured party’s workers’ compensation case? Yes No
If this is an asbestos case, is your office filing any of the bankruptcy or administrative claims? Yes No If “yes”, which one(s)?
Did the injured party sign a fee contract with your firm? Yes No If so, please forward upon acceptance of the case.
Please confirm that we have permission to contact the injured party. Yes No If yes please provide contact information:
Contact Person’s Name:
Address:
City:
State:
Postal Code:
Phone Number:
E–mail Address: (Privacy Policy)
Other Comments: