Palm Beach Gardens
561-671-5995
Fort Lauderdale
954-272-6187
Home
Practice Areas
DUI Defense
BUI/Boating Intoxicated
DUI & DMV Hearings
Criminal Defense
Aggravated Assault
Aggravated Battery
Battery
Carjacking
Domestic Violence Defense
Domestic Violence Injunction
Drug Possession
Drugs With Intent to Sell
Drug Trafficking
Firearms and Weapons Charges
First-Time Offenders Defense
Fraud and Financial Crimes
Grand Theft
Home Invasion
Juvenile Defense
Marijuana Defense
Out-of-State/Tourist Defense
Petit Theft
Probation Violation Defense
Seal & Expunge
Theft
Mugshot Removal Services
Personal Injury
Car Accidents
Dog Bites
Gym Injuries
Sidewalk Injuries
Slips & Falls
Wrongful Death
Amusement Park Injuries
See All Practice Areas
About Us
Matthew Konecky
Samuel Meshulam
Nyssa Hardy
Martaluz Cisneros
Ashley Glasser-Konecky
Locations
Reviews
Blog
Helpful
Info
FAQs
Results
Videos
Instant Downloads
Contact
Us
Personal Injury Intake Form
Fill Out the Form Below
Caller Name if not Injured Party
Caller Number if not Injured Party
First Name
*
Last Name
*
Address
City
State
Zip
Country
Phone
Email
Type of Case
*
Auto Accident
Slip/Trip Fall
Other
How Did You Hear About Us?
Driver's License #
Date of Birth
Employer (List name and Address)
Date of Incident
County of Incident
Reason for Seeking Consultation with our Office
Cross Streets of Accident
Description of What happened
Witnesses? List name and phone number.
Police Responding
Police Report #
Transported by Ambulance?
Yes
No
Ambulance Service Used
Description of Injuries
Hospital
Treating Doctors
PIP INSURANCE
Client's PIP Claim #
Defendant Insurance
Defendant's Claim #
Client's Health Insurance Company
Workers Comp Claim Filed?
Yes
No
N/A
Previous Accident Injury Or Claim
Previous Accident or Injury Claim
Yes
No
Your Goal for this case
Submit
