Raynor, Rensch, & Pfeiffer, NE | Omaha Family Law Attorneys | Columbus Commercial & Residentail Real Estate Lawyers

Personal Injury Lawyer

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Who was injured?

If "Other ", please describe:

Injured person's name (if different from above):

Address:

City:

State:

Zip:

E-mail address:

Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

When did the injury occur?

Where did the injury occur?

Was this location the injured person's

If "Workplace," did the injury occur as a result of employment activities?
YesNo

If "Other," was this a road accident?
YesNo

If no, did the injury occur on another's property?
YesNo

If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?
YesNo

If yes, what are their names/contact information?

Were others involved or injured at the same time?
YesNo

If yes, what are their names/contact information?

Was there a police report?
YesNo

Did the injured person receive medical treatment?
YesNo

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
YesNo

Was the injured person killed as a result of the accident?
YesNo

If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

Where did you hear about this website?

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Who was injured?

If "Other ", please describe:

Injured person's name (if different from above):

Address:

City:

State:

Zip:

E-mail address:

Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

When did the injury occur?

Where did the injury occur?

Was this location the injured person's

If "Workplace," did the injury occur as a result of employment activities?
YesNo

If "Other," was this a road accident?
YesNo

If no, did the injury occur on another's property?
YesNo

If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?
YesNo

If yes, what are their names/contact information?

Were others involved or injured at the same time?
YesNo

If yes, what are their names/contact information?

Was there a police report?
YesNo

Did the injured person receive medical treatment?
YesNo

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
YesNo

Was the injured person killed as a result of the accident?
YesNo

If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

Where did you hear about this website?

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

What type of family law matter are you interested?

Are you currently married or cohabiting?
YesNo

Check one:
MarriedCohabiting

If yes, list his or her name, date of birth, and date of marriage/cohabitation:

Do you have children?
YesNo

If yes, list their names and dates of birth:

Name	Date of Birth

If you have children, with whom and where do they live now?

Were you previously married?
YesNo

If yes, when and how did your previous marriage(s) end?

Is your case contested or do you anticipate you will meet opposition to your anticipated actions?
YesNo

Have you been served with papers in a family law matter?
YesNo

If yes, What is the name of the opposing party and his or her attorney (if known)?

What is your relationship with the opposing party?

If "Other Relationship", please explain:

Have you appeared in court or agreed on terms related to this matter?
YesNo

Do you have copies of any documents (court decrees, dissolution agreements, etc.) related to this matter?
YesNo

What types of documents do you have?

Is domestic violence an issue in this matter?
YesNo

If yes, please describe, including any court actions and incident dates:

Is property at issue?
YesNo

If yes, please describe the property and anything known with regard to legal ownership:

Are you or any person involved in this matter currently pregnant?
YesNo

Where did you hear about this website?

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Who was injured?

If "Other ", please describe:

Injured person's name (if different from above):

Address:

City:

State:

Zip:

E-mail address:

Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

When did the injury occur?
Where did the injury occur?
Was this location the injured person's
If "Workplace," did the injury occur as a result of employment activities? YesNo
If "Other," was this a road accident? YesNo
If no, did the injury occur on another's property? YesNo
If yes, who owns the property?
How did the injury happen?
What were the surrounding circumstances (weather, lighting, slipperiness, other)?
Were there witnesses to the injury? YesNo
If yes, what are their names/contact information?
Were others involved or injured at the same time? YesNo
If yes, what are their names/contact information?
Was there a police report? YesNo
Did the injured person receive medical treatment? YesNo
If yes, provide dates, locations, provider names, and details:
Is the injured person still receiving treatment? YesNo
Was the injured person killed as a result of the accident? YesNo
If yes, what was the date of his or her death?
Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:
Describe other losses resulting from the injury (lost wages, damaged property, other):
Where did you hear about this website?

NOTE: The use of the Internet for communications with the firm will not establish an attorney-client relationship and messages containing confidential or time-sensitive information should not be sent.

Our personal injury attorneys work on contingency.

From offices in Omaha and Columbus, NE, Raynor, Rensch & Pfeiffer serves clients in eastern Nebraska, western Iowa, and the Missouri Valley, including the cities of Council Bluffs, Lincoln, Columbus, Bellevue, Ralston, Blaire, Papillion, Grand Island, Kearney, Hastings, Plattsmouth, Nebraska City, Norfolk, Wahoo, and throughout Douglas County, Pawnee County, Sarpy County, Washington County, Dodge County, Platte County, Pottawattamie County, and Lancaster County.

Raynor, Rensch & Pfeiffer
10110 Nicholas Street, Suite 102
Omaha, Nebraska 68114
Toll-free: (800) 471-4100
Phone: (402) 498-4400
Fax: (402) 498-0339

1470 25th Avenue
Columbus, NE 68601
(402) 562-7759

The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation.

Copyright © 2008Raynor, Rensch & Pfeiffer. All rights reserved. You may reproduce materials available at this site for your own personal use and for non-commercial distribution. All copies must include this copyright statement.