Kossover Law Offices, LLP

Intake Sheet

Kossover Law Offices would be happy to review your situation without obligation to you. Simply fill out the following information and click the submit button at the bottom of the form. One of our experienced attorneys will review the information and contact you by return email or by telephone. Until we have informed you, in writing of our representation, you should not assume that our office has been retained to represent you.

Required fields are marked with and asterick (*).

* First Name:

* Last Name:

* Home Address:

Phone:

* (H)

(W)

* Employer Address:

Job Title:

* Date of Arrest/Accident:

* Time of Arrest/Accident:

* Brief Description of Incident:

* If Accident,
Describe Your Injuries:

If Arrest, Next Court Date:

Court Location:

Ambulance:

Hospital Name:

Doctor's Name: