Wrongful Death Claim Evaluation Form

Name
Email Address:
Phone:
How are you related to the decedent?
Have you been appointed as the personal representative of the decedant's estate? Yes No
When did the decedent die?
What was the cause of death?
Was the decedent married or single? Married Single
Was the decedent employed at the time of death? Yes No
Were you dependent upon the decedent for financial support? Yes No
Did the decedent leave children? Yes No
Is the decedent a minor? Yes No
Did an accident occur which caused the death? Yes No
If yes, please provide a general description
How did you hear about us?

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