If a close relative of yours died as a result of an accident or medical malpractice, please complete and submit the form below, to see if we can help to obtain monetary compensation for your tragic loss.

1. Name*
2. Email*
3. Phone
4. Name of deceased
5. Your Relationship to Deceased
6. Age of Deceased
7. Date of Death
8. If the death was caused by an accident, please complete the following
9. Date of Accident
10. Location of Accident (Please include City or Town, and State)
11. Describe The Accident (Please include a description of what caused the accident, and who was at fault.)
12. Describe The Injuries & Treatment
13. For motor vehicle accidents, describe the damage to the vehicles
14. Did the police respond to the accident?
15. Yes No
16. If so, do you have a police report?
17. Yes No
18. If the death was caused by medical malpractice, please complete the following
19. Date or dates when the improper medical treatment occurred
20. Doctor who committed the medical malpractice (Please include Doctor’s Name, City or Town, and State)
21. Hospital where the medical malpractice occurred (Please include Hospital Name, City or Town, and State)
22. Medical condition for which the deceased was treated, and the type of treatment he or she received
23. Your understanding of how the medical treatment was improper
24. Has another doctor advised you that the medical treatment was improper?
25. Yes No
26. Describe the injuries or medical conditions that were caused by the improper medical treatment, and explain how that resulted in death.
27. For security purposes, please answer the question below
28. 9+1

 

*Required

Please click the Submit button. If you do not receive a confirmation message, an error has occurred. Therefore, kindly confirm the required fields (including Name and Email) and verify the security code. Then please submit this form again, or click the reverse arrow in your browser.

Notice: Your submission of this form, or a free telephone consultation, will not constitute an attorney-client relationship.

New York Injury Attorney Disclaimer: The New York personal injury, wrongful death, accidental death, medical malpractice, accident, injury, serious accident, or other personal injury legal information contained in this website is not intended to constitute legal advice, nor to create an attorney-client relationship or lawyer-client relationship. We recommend that you discuss your accident case with a Personal Injury Attorney or Accident Lawyer practicing law in New York promptly, since there are strict time limitations that apply to New York injury lawsuits. This website is not intended to solicit clients for accident cases outside of New York State. Under New York law, in the event there is no recovery in a contingency fee case, the client is responsible for the expenses of the litigation, including court costs and disbursements.

New York Personal Injury Lawyers and Attorneys New York representing accident victims who have sustained serious injuries in New York City, Manhattan, Bronx, Brooklyn, Queens, Staten Island, Long Island, Nassau County, Suffolk County, Westchester County, Rockland County and upstate New York.