Free Case Evaluation

The information you submit will be kept completely confidential. It is important that you completely fill out this form. If we decide to accept your case, the information you submit here will be used to contact you and prosecute your case. The more information you supply, the better we can evaluate your case. Required fields are marked with an asterisk (*).

*Name:

Address:

City:

State:

Zipcode:

*Email:

Home Phone:

Work Phone:

Cell Phone:

*Make and Year of the car:

*Model:

Where was car purchased?

Has the car been in an accident?

If yes, where? Describe:

*Vin Number:

Did you purchase an extended warranty?

How many miles were on the car at the time of purchase?

If yes, describe damage:

Has the car been serviced somewhere besides the dealer?

Did you purchase or lease the car?

Was the car new or used?

Date of purchase/lease:

Purchase price/Lease cost:

*Name of Dealer:

Address:

City:

State:

Zipcode:

Who arranged financing?

Did the car come with a warranty?

How long?

Did you purchase an extended warranty or service contract?

How long?

*Describe your problem:

In the spaces provided, please list the SYMPTOMS that you have experienced with your vehicle, the number of trips to the dealer for each symptom (whether documented or not), and the approximate date(s) when the vehicle was inspected and/or repaired for each symptom.

Symptoms (Defects and Nonconformities)	Number of Trips to Dealer	Date(s) in Repair Shop
1.	1.	1.
2.	2.	2.
3.	3.	3.
4.	4.	4.
5.	5.	5.
6.	6.	6.

Total Number of Repair/Work Orders in your possession:

Approximate Total number of CALENDAR DAYS vehicle has been out of service and/or in the repair shop:

greater than/equal to 30 days

less than 30 days

Additional Comments:

Disclaimer:

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