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Wrongful Death Form

If you are interested in having LeClair & LeClair, P.C. handle your case, please feel free to fill out the following client information form.  If you have sent us a client information form and have not heard from us within 24 hours, please make sure that you telephone us to insure we received your information.  Prior to LeClair & LeClair, P.C. accepting any case and assuming responsibility for that case, you will have to have a consultation with one of our attorneys and a written fee agreement will have to be executed by you and LeClair & LeClair, P.C..  While not all injuries give rise to a cause of action, we are willing to provide you with a free, no commitment consultation to discuss your case.  Whether or not LeClair & LeClair, P.C. agrees to handle your case, any information that is provided to us will be kept confidential and will not be given to any third party without your consent.

General Information

E-Mail Address:
Today's Date:
City: State: Zip Code:
Home Phone:
Work Phone:
Social Security Number:

Please Provide Decedent Information

City: State: Zip Code:
Date of Birth:
Date of Death:
Social Security Number:
Spouse's Name:
Number of Children:
How did you hear of LeClair & LeClair, P.C. Law Firm?

The Death

Explain how the death occured:
If this was an auto accident was the deceased driving or passenger?
Was there a police report? yes no
  Did you get a copy? yes no
Was there a traffic ticket issued? yes no
  To Whom?
  For What?
Did the defendent say anything admitting fault? yes no
If yes, what did he/she say?
Did the defendent's insurance company pay property damage? yes no
  Amount they paid:
  If not, who paid?
* please provide pictures of the damaged vehicles if you have them.
If the death did not occur in an automobile accident, please explain how it occurred.
Do you have any pictures that may help with this case? yes no
What are the names of the witness(es) to the accident:

Injuries / Death

Did the deceased go to the emergency room? yes no
  If yes, where?
Did he/she go in an ambulance? yes no
What were the injuries from this accident?
Please list the doctors and all medical providers the deceased saw for injuries from this fall:
What is the total amount of your medical bills?
  Have any of them been paid yet? yes no
  By who / what insurance company?
What Funeral Home was used for the decendent's burial?
  Are there any expenses owed for the funeral? yes no


Has there been an Estate opened for the decendent? yes no
  If yes, who is the attorney?

Work Losses

Employer's name:
What was the deceased's hourly pay rate?
What were his/her work duties?

Insurance Information

Decedent's Auto Insurance Company:
Company name:
Phone number:
Insurance claim number:
Decedent's Health Insurance Company:
Company name:
Phone number:
Insurance policy number:
Insurance claim number:
Defendant's Auto Insurance Company:
Company name:
Phone number:
Insurance claim number:

Additional Information

Please provide any other insurance the decedent had such as, life ins. policies, mortgage, other loan or credit card death benefit policies or the like.

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This web site is designed for general information only.  The information presented at this site should not be construed to be formal legal advice nor the formation of a lawyer/client relationship.  Persons accessing this site are encouraged to seek independent counsel for advice regarding their individual legal issues.