RICHARD ALLAYE CHAN, JR. - SACRAMENTO ATTORNEY

Sacramento Personal Injury Attorney, Sacramento Injury Lawyer

Please fill out the following Case Evaluation form and provide as much information as possible. All information is kept strictly confidential and is used only by The Law Offices of Richard Allaye Chan, Jr. for the evaluation of your case. By accepting and reviewing this completed form, we are not agreeing to represent you. Rather, we will evaluate your information to determine whether or not we can accept your case.

CONTACT INFORMATION
* Your Name:
* Home Address:
* City:
* State:	- CA-California - AL-Alabama AK-Alaska AZ-Arizona AR-Arkansas CA-California CO-Colorado CT-Connecticut DE-Delaware D.C.-Dist. of Columbia FL-Florida GA-Georgia HI-Hawaii ID-Idaho IL-Illinois IN-Indiana IA-Iowa KS-Kansas KY-Kentucky LA-Louisiana ME-Maine MD-Maryland MA-Massachusetts MI-Michigan MN-Minnesota MS-Mississippi MO-Missouri MT-Montana NE-Nebraska NV-Nevada NH-New Hampshire NJ-New Jersey NM-New Mexico NY-New York NC-North Carolina ND-North Dakota OH-Ohio OK-Oklahoma OR-Oregon PA-Pennsylvania RI-Rhode Island SC-South Carolina SD-South Dakota TN-Tennessee TX-Texas UT-Utah VT-Vermont VA-Virginia WA-Washington WV-West Virginia WI-Wisconsin WY-Wyoming
* Zip Code:
* Home Telephone:
* Email Address:
INJURY INFORMATION
Injury type:
Where did injury occur?
Date & Time of injury:
Other party's insurance:
How did the injury accur?
Who was at fault & why?
List prior injuries:
Comments:
Image Varification: