Personal Injury
If you believe that you or someone close to you may have a personal injury claim or a criminal defense matter, please fill out the following questionnaire. By submitting the information below, you will enable the attorneys at The Wilbur Smith Law Firm to evaluate your case based on its merits. Please be as complete as possible in the information you provide. If you have a potential case related to a DUI, please fill out our DUI case evaluation form. If you would like to contact The Wilbur Smith Law Firm for reasons other than a possible personal injury claim or a criminal defense matter, please use our General Contact Form.
Your Name: (required)

Street Address:

City:

State:

Zip:
 E-mail Address (required)

Home Phone:

Work Phone:

Fax Number:
Preferred method of contact:
What time of day would you like us to call?

General Incident Information:

Date that the incident occured (00/00/00): / /

Where did the incident occur?

Please briefly describe the incident: (required):
Important Legal Disclaimers:
Yes No - I agree that this matter may be referred to an attorney in my area who may contact me.

Yes No - I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this
e-mail question.

Yes - I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement.

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1415 Hendry Street · P.O. Drawer 8 · Fort Myers, Florida 33902-0008
Phone: (239) 334-7696 · Fax: (239) 334-3669 · Email: info@wilburlaw.com
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