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Fifth Third Center 201 E. Kennedy Blvd. Suite 1475 Tampa, FL 33602
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Wrongful Death Case Evaluation

Please answer as many of the following questions as you can.


Name:
Address:
City:
State:
Zip Code:
Email Address:
Phone Number:
Name on the deceased:
What is your relation to the deceased?
Who caused this wrongful death?
What exactly occurred to cause this loss?
How could this loss have been avoided by the at-fault party?
Was the deceased married? Separated or Divorced? To whom?
Did the deceased have children? How many? Name(s) & Age(s) of all?
How many people were in the lost love one’s immediate family?
Who else did the deceased individual support? Name(s)& Age(s) of all?
How has this loss emotionally and financially affected the deceased’s family’s life?
Any other special concerns?
 
DISCLAIMER: Sending an email through this form will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. Please do not send sensitive or confidential information via this email form. Email sent via the Internet might be intercepted and read by third parties.
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Subject:
Your Name:
* Your Email Address:
Your Phone Number:
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Your Message:
 
DISCLAIMER: Sending an email through this form will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. Please do not send sensitive or confidential information via this email form. Email sent via the Internet might be intercepted and read by third parties.
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Address: Fifth Third Center   201 E. Kennedy Blvd, Suite 1475   Tampa, FL 33602   Toll Free: 877-888-JURY Phone: 813-223-7799