Contact Contact Reach Out to Us at DiBella & Laurean LLC Full Name* First Last Phone*Email* What type of case? Personal injury Divorce Real estate DUI Traffic ticket Criminal What was your date of arrest and/or ticket? MM slash DD slash YYYY When is your next court date? MM slash DD slash YYYY Where is your next court date? MM slash DD slash YYYY Are your buying or selling real estate? Buying Selling What county are you located in? Cook Dupage Is it an existing or a new case? Existing case New case Are kids involved? Yes No How Were You Hurt? Automobile Accident Pedestrian or Bicycle Accident Motorcycle Accident Truck Accident Workplace Accident or Injury Medical Negligence Slip or Fall Injury Other Accident or Injury Was a police report filed? Yes No I don’t know Was the at fault party ticketed? Yes No I don’t know Did the injury occur at work? Yes No Was the Injury Reported to your Employer? Yes No Were you taken to the hospital by an ambulance? Yes No Did You Follow Up With Your Own Doctor? Yes No What Were The Injuries? - Check all that apply Back or neck pain Broken bone(s) Cuts and Bruises Headaches Memory Loss Loss of Limb Death Other Other Injuries: Fill in blank/describe Do You Currently Have an Attorney Representing You? Yes No Were You At Fault For This Accident? Yes No When Did The Accident or Injury Occur?In the last 30 days1-6 months ago6-12 months ago1-2 years agoOver 2 years agoEmailThis field is for validation purposes and should be left unchanged.
