The Law Office of Jack E. Brackney

Attorney and Counselor at Law

(877) 679-5225
jack@brackneylawoffice.com

39-20 59th Street, Suite 2
Woodside, New York 11377

815 Superior Avenue East, Suite 1618

Cleveland, Ohio 44114

Thank you so much for contacting our law office! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security Number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security Numbers are most often used to positively identify parties. Most courts require Social Security Numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in court orders
in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Preferred Contact Method

Social Security Number

Driver's License Number

Marital Status

Single

Married

Separated

Divorced

Widowed

Are you currently employed?

Yes

Did you miss work as a result of your accident?

Yes

Do you have a prior criminal record?

Yes

Do you have a prior traffic citations?

Yes

Do you have social media?

Yes

How many vehicles were involved in the accident?

Other Driver(s)

Please provide as much information as possible.

Other Driver's Name

Other Vehicle License Plate Number

Did you speak to any other drivers at the scene?

Yes

Did you obtain insurance information for the other driver(s)?

Yes

Notes about other driver(s) or location of incident:

Did you have passengers in the vehicle?

Yes

Are you aware of any other lawsuits stemming from this accident?

Yes

Have you been involved in any car accidents PRIOR to this accident?

Yes

Have you been involved in any car accidents AFTER this accident?

Yes

Facts of the Accident

Please provide as much information as possible. Be as specific as you can, but try to stick to the facts. You will have the opportunity to tell me the whole story during your free consultation.

Date of accident:

Approximate time of the accident:

Location of the accident:

Vehicle your were driving:

License plate state and number:

Vehicle other driver(s) were driving:

License plate state(s) and number(s):

Did police respond to the scene?

Yes

Describe the weather at the time of the accident.

What caused the accident?

Example: "I was stopped at a red light and a car struck my vehicle from behind."

Did you take pictures of the scene or vehicles?

Yes

Witnesses to the accident:

Where was the damage to your vehicle? Check as many as applicable.

If other, please explain.

Description of the accident:

Was an ambulance called to the scene?

Yes

Medical Information

Please tell me about the injuries you received as a result of your accident.

What body parts were injured?

Did you undergo surgery as a result of the injuries?

Yes

If you hade surgery, what was the date?

Where did you first receive medical treatment for the injuries?

What was the date you first received treatment?

Important: Please tell me about prior injuries or treatment received for the body parts injured in this accident.

List all medical providers you saw for the injuries:

Ongoing symptoms/Medical treatment:

Additional Materials to Provide for Your Consultation

Please provide any of the following information and/or documentation which you have available. You are not required to provide any of these materials for your consultation. Any materials you provide will help us to determine the status of your case, but at this time it is not necessary for you to request materials you do not have available. Please provide all of the following that you have available to jack@brackneylawoffice.com.

Please provide the following if available:

Accident report (If no law enforcement report was made, please bring insurance information for all involved parties.)PhotographsNames and contact information for all involved partiesNames and contact information for all witnessesHealth insurance card(s)Time missed from work, documentation of earnings at time of accident, and date of hireDismissal/discharge summary from ER or hospitalMedical BillsDocumentation for out-of-pocket expenses

Other information/materials you feel may be relevant to your case:

How were you referred to Jack?

Friend or family member

Another attorney

Online search or lawyer directory website

Billboard, bus stop, phone book, newspaper, or other physical advertisement

Radio or TV advertisement

Bar Association

Other

ACKNOWLEDGEMENT AND ACCEPTANCE

I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.

THANK YOU

If you have any written documents or witness statements regarding your claims, please email this fact sheet, together with those documents to jack@brackneylawoffice.com.

Thank you for contacting The Law Office of Jack E. Brackney regarding your legal claims or questions. We value each potential client who contacts us and will make arrangements to meet or speak with you when convenient, including Saturdays. Please be advised, however, that The Law Office of Jack E. Brackney is not your legal counsel until there is a signed fee agreement in place between you and the firm. By submitting this form, you are requesting that we evaluate whether you have a valid claim. We have not agreed to act as your legal counsel.