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Contact Information

Full Name: * Email Address: * Phone Number: * Preferred Method of Contact: * Best Time to Contact (Mon–Fri, 9AM–5PM): *

Case Type

Is this a Personal Injury case? *

Incident Details

Date of Incident: Time of Incident: Location of Incident (Street, City, State): Type of Incident (e.g., Traffic Accident, Slip and Fall, etc.): Brief Description of How the Incident Occurred:

Injuries Sustained

Please describe your injuries: Have you sought medical attention? If yes, please list the medical facilities and dates of treatment: Are you currently receiving medical treatment? If yes, please describe the treatment: Have you missed time from work due to your injuries? If yes, approximately how much time have you missed? Are you able to perform your daily activities as before the incident? If no, please describe any limitations:

Other Parties Involved

Were there other parties involved in the incident? If yes, please provide any known information about them: Were there any witnesses to the incident? If yes, please provide their contact information:

Insurance Information

Do you have health insurance? If yes, please provide the insurance company name and policy number: Do you have auto insurance (if applicable)? If yes, please provide the insurance company name and policy number: Do you know if the at-fault party has insurance?

Additional Information

Is there anything else you would like us to know about your case?

Disclaimer

Please be advised that the submission of this form does not, in any way, establish an attorney-client relationship. All information disclosed within this form will be treated with the utmost confidentiality and will be securely maintained. We are committed to protecting your privacy and ensuring the security of your data

Contact Info

Address

425 Grand Concourse Bronx, 10451

Phone Number

347-918-1847

E-Mail

Alex@alexdiazpc.com

Schedule

9:00 AM - 5:00 PM Monday- Friday

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Contact Us

Intake Form

Contact Information

Case Type

Incident Details

Injuries Sustained

Other Parties Involved

Insurance Information

Other Legal Issue

Additional Information

Disclaimer

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