Guy Kornblum & Associates - Do You Have a Case?

Name:
Address:
City:
State:
Zip:
Phone:
Email:

Employer's Name/Address:

Work Phone:

Name of Insurance Company (if one is involved, as it appears on the first page of the insurance policy):

Name/Address/Tel. No. of any insurance agent:

Type of Policy:

Date when the claim (against potential parties repsonsible for any wrongdoing) made?

What is your case about; please give us a brief statement of your story:

How was the claim made to the wrongdoer:
Through Agent (if agent's contact information different from what you provided above, please provide their name/address/phone no. below):

By phone,
By claimform

Has a decision been made about your claim?
Yes, No

If so what was the decision and how did you learn about it?

Please provide a list of your damages; please describe and provide figures - if you can?

If applicable, what is your complaint about what any insurance company has done?

How did you first hear about us?

If you selected "Other" above, please specifiy:

If referred by an attorney, please specify the attorney's name:

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