Wrongful Death Contact Form

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

How are you related to the decedent (the person who passed away)?

Have you been appointed as the personal representative or executor of the decedent's estate?
Yes  No 

When did the decedent die?

What was the cause of death?

Was an autopsy conducted?
Yes  No 

Was the decedent married or single?
Married  Single 

Is the decedent a minor?
Yes  No 

Did the decedent leave children?
Yes  No 

Was the decedent employed at the time of death?
Yes  No 

Were you dependent upon the decedent for financial support?
Yes  No 

Were other family members dependent upon the decedent for financial support?
Yes  No 

Do you have reason to believe the decedent experienced pain or suffering as a result of an incident that contributed to his/her death?
Yes  No 

Did an accident occur which caused the death?
Yes  No 

Is there any indication that the poor medical treatment contributed to cause the decedent's death?
Yes  No 

Please note any other concerns:

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