Insurance Intake Form

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Details Name Please enter your name.

Street Address Please enter your street address.

City Please enter the name of your city.

State Please choose your state of residence. ZIP Code Please enter a valid ZIP code. You may use 0-9, spaces and the ( ) - + characters.

E-mail Address

Please enter a valid e-mail address.

Home Phone Number Please enter a valid home phone number. You may use 0-9, spaces and the ( ) - + characters.

Business Phone Number Please enter a valid business phone number. You may use 0-9, spaces and the ( ) - + characters.

Mobile Phone Number Please enter a valid mobile phone number. You may use 0-9, spaces and the ( ) - + characters.

Fax Number Please enter a valid fax number. You may use 0-9, spaces and the ( ) - + characters.

What type of insurance does this matter concern? Please indicate which type of insurance this matter concerns. What is the name and address of the insurance company involved? Please enter the name and address of the insurance company involved.

Is the insurance policy in your name? The insurance policy is in my name.

The insurance policy is not my name.

If the insurance policy is in your name, please enter the name and address of the agent who issued the policy. Please enter the name and address of the agent who issued the policy.

Does this involve a business you own or run? This matter involves a business I own or run.

This matter does not involve a business I own or run.

If this matter involves a business you own or run, please enter the business's name, address and phone number. Please enter the business's name, address and phone number.

Please briefly describe your situation, including any relevant dates. Please briefly describe your situation, including any relevant dates.

How would you rate your legal needs described above? Please indicate the urgency of your legal needs described above.

Are any other people involved? Other people are involved.

No other people are involved.

If other people are involved, please list their names, addresses and their relationship to you, if any. Please list their names, addresses and their relationship to you, if any.

Do you have any documents that may help explain your situation? I have documents that help explain this situation.

I do not have documents that help explain this situation.

If you have related documents, please list them and any corresponding dates. Please list the documents in your possession and any corresponding dates.

Are there other helpful documents that you do not have access to? There are other helpful documents that I do not have access to.

I am not aware of any other helpful documents.

If there are other helpful documents that you don't have access to, please list them and any corresponding dates and locations. Please list the documents you don’t have access to and any corresponding dates and locations.

Describe how this situation has affected you. (Or: Describe the impact this situation has had on you and/or your business.) Please describe how this situation has affected you. (Or: Please describe the impact this situation has had on you and/or your business.)

How would you like this issue resolved? What's your preferred outcome? Please describe how you would like this issue to be resolved or your preferred outcome.

Have other attorneys worked on this matter? Other attorneys have worked on this matter.

Other attorneys have not worked on this matter.

If other attorneys have worked on this matter, please provide their names, addresses and a brief description of their involvement. Please provide the names, addresses and a brief description of the other attorneys' involvement.

Describe any special concerns. Please describe any special concerns.

How did you hear about this Web site? How did you hear about this Web site? Please choose one.

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

Please verify that you have read the disclaimer. I have read the disclaimer.

Brookhaven Office
512 W. Monticello Street
Brookhaven, MS 39601
Phone: 601-823-7100
Toll Free: 866-823-7100

Map and Directions

Hattiesburg Office
301 W. Pine Street
Hattiesburg, MS 39401
Phone: 601-255-4484
Toll Free: 888-493-4099

Map and Directions

*FREE BACKGROUND INFORMATION AVAILABLE UPON REQUEST.

The Burghard Law Firm, PLLC, serves clients in South Mississippi and the Mississippi Gulf Coast, including Hattiesburg, Brookhaven, Natchez, Gulfport, Biloxi, Pascagoula, Laurel, Long Beach, the Jackson metro area, McComb, Picayune, Columbia, Lucedale, Forrest County, Lincoln County, Harrison County, Jackson County, Jones County, Pearl River County, Hancock County, Lamar County, Hinds County, Rankin County, Madison County, Pike County, Adams County, Lincoln County, Copiah County, Scott County, Simpson County and Marion County.

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