The Law Offices of Jesus Zuniga

If you have a legal matter, whether you're an individual, a professional, a business owner, or whether you represent a corporation, it is paramount that you hire the best legal team you can. Don't leave your outcome up to chance! Our office is known for, and has a reputation for, fighting effectively and aggressively to defend our clients' interests.

	FAMILY LAW
	Divorce Custody Restraining Order Child/spousal Support Contempt
	BANKRUPTCY
	Chapter 7 Chapter 13
	Accidents
	Auto Motorcycle Slip and Fall Wrongful Death Serious Injuries
	CIVIL LITIGATION
	Breach of Contract Fraud/Misrepresentation Real Estate Disputes Wills and Trusts
	Criminal law
	Domestic Violence D.U.I. Theft/Embezzlement


NAME	:
STREET ADDRESS	:
CITY
STATE/ZIP
COUNTY OF RESIDENCE	:
HOME PHONE	:
WORK PHONE	:
EMAIL	:
PERSONAL DATA	:
AGE	:
DATE OF BIRTH	:
SOCIAL SEC. NO	:
DRIVER'S LIC. NO	:
STATE	:
TYPE	:
EXPIRATION DATE	:
OCCUPATION/PROFESSION	:
EMPLOYER	:
EMPLOYER'S STREET ADDRESS	:
EMPLOYER'S CITY/COUNTRY	:
STATE OR ZIP	:
WORK SCHEDULE
DAY OF WEEK	:
HOURS	:

MARITAL STATUS	:
SPOUSE	:
CHILDREN	:
GENERAL INFORMATION
Date and Time of Accident	:
Location of Accident (Highway/Street Name, City, County, State)	:
Client's Involvement (Driver, Passenger, Owner, etc.)	:
How Accident Happened	:
Types of Vehicles Involved	:
Potential Problems (Weather, Contributory Negligence, Mechanical Failure, Alcohol, Drugs, etc.)	:
Persons/Parties Responsible for the Accident	:
Who Investigated Accident (Police, Insurance Adjuster, etc.)	:
Charges Filed and Against Whom	:
Disposition of Charges	:
Witnesses	:
Photographer or Videotaper	:
Statements Made	:
Injuries:	:
Medical Expenses	:
Other Expenses	:
Loss of Earnings	:
Treating Physicians	:
Emergency Room	:
Hospital Admission	:
Medical Treatment and Tests	:
Medications Prescribed	:
Present Condition	:
Insurance Coverage of Defendant (Solvency, if uninsured)	:
Insurance Adjuster	:
Offers of Settlement	:

Insurance Coverage of Client (Liability, Uninsured / Underinsured Motorist, Personal Injury Protection, Medical Payments Coverage, Personal/Group Health and Accident Coverage, Disability, etc.)


*ERISA Plan: (Name of Employer, Subrogation Provisions, Provisions Giving Plan Administrator the Right to Interpret Plan Provisions):


*Note: that ERISA preempts state law on subrogation rights. An ERISA plan may have the right, under federal law, to claim the entire recovery until its entire subrogation has been collected.

How Does Plan Administrator Interpret Subrogation Rights	:
Prior Injuries and Illnesses	:
Prior Suits and Claims	:
Prior Arrests and Convictions	:
Driving Record	:
Plaintiff	:
Defendant	:
Educational History	:
Employment History	:
Marital History	:



Disclaimer: By pressing Submit I agree that the information provided herein does not create an attorney client relationship. Hence, I do not expect such information to be confidential unless and until the Law Offices of Jesus Zuniga contacts me after doing a conflict check and advises me that the communication between us is confidential.