Personal Injury Information Form

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Are you known by any other names?
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If yes, list other names you have used:

What is your marital status?

Does this matter involve a business you own or run?
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If yes, provide the business name, address, and phone:

If a business is involved, how is the business organized (if known)?

Are you employed?
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If yes, please provide your job title and employer's name and address.

Can you be contacted at work?
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What area of law does your situation involve (if known)?

Describe your situation, including any relevant dates:

How would you rate your legal needs described here?

Are any other people involved?
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If yes, provide names, addresses (if known), and their relationship to you, if any:

Do you have any documents that could help explain your situation?
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If yes, list those documents and their dates:

Are there other documents that you do not have access to that could be of assistance?
Yes  No 

If yes, list those documents and their dates and locations (if known):

Describe how this situation has impacted you:

Describe what you would like to happen to resolve your issue (your preferred outcome):

Have other attorneys worked on this matter?
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If yes, provide names, addresses, and a brief description of their involvement:

Special concerns:

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From offices in Brandon and Tupelo, the attorneys of Fox Law Group, PA, represent clients in Mississippi, Arkansas, and Tennessee, including the cities of Hattiesburg, Jackson, Tupelo, MS, and Memphis, TN, as well as residents of Hinds County, Itawamba County, Lee County, Monroe County, Pontotoc County, Prentiss County, Rankin County, Tippah County, and Union County, in Northeast Mississippi, Shelby County, Tennessee, and travelers on I-55, I-20, and Hwy. 78.


Toll Free: 1(866) 588-4369

Fox Law Group, PA
Brandon Office (Main)
276 Maxey Drive
Brandon, MS 39042
Tel: (601) 825-6111
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Tupelo Office
84 Clark Boulevard
Tupelo, MS 38804
Tel: (662) 844-2068
Fax: (662) 844-1068
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