Barry & Loewy LLP encourages prospective clients and referring counsel to contact us for a FREE initial consultation about the specifics of your case.

You may contact us by phone at (800) 892-5044, or by email at info@barryloewy.com. You may also contact us by filling out the electronic Questionnaire below.

First Name: *
Last Name: *
Street Address:
City, State, Zip:
Home Phone: *
Work Phone:
Email: *
What is the best way to reach you?
Are you seeking information for yourself or someone else?	Yes No
Is an attorney currently representing you in this matter?	Yes No
How did you hear about us?	Select ----------------------- Consultwebs Directory Direct Mail Print Ad Print Directory Radio Referral Search Engine TV Web Directory Yellow Pages Other
Accident Information
Date of truck accident:
Time of truck accident:
Location of truck accident (include city, state and specific street names, if possible)
What caused the truck accident?
Did injuries result to you, your passengers, or the other driver and passengers as a result of the truck accident?	Yes No
If you have injuries, do they prevent you from working?	Yes No
If yes:
When did you stop      working?
How much income have      you lost as a result of      the truck accident and      your injuries?
What are your medical expenses to date?
Is there damage to your vehicle or the other driver’s vehicle?	Yes No
If yes:
What is the approximate      damage to your vehicle?
Are you renting a       vehicle and, if so, what      is the cost?
What is the approximate      damage to the other      driver’s vehicle?
Do you have a copy of the police report?	Yes No
Was the truck driver of the other vehicle charged with a DUI?	Yes No
Name of your auto insurance company:
Name of the other driver’s auto insurance company:
Any other information you feel is valuable to your truck accident case:
	Please do not include any confidential or sensitive information in this form. This form sends information by non-encrypted e-mail which is not secure. Submitting this form does not create an attorney-client relationship.