CONFIDENTIAL SERIOUS PERSONAL INJURY INQUIRY FORM*

You may Email by clicking on the submit button below or print this form to mail or fax to us:

Burkhalter, Rayson & Associates, P.C.

P.O. Box 2777

Knoxville, TN 37901-2777

Fax No.: (865) 524-0172

To request more information, please complete the form below.
*Bold fields are required*

*Email:*

*Your Name:*

*Date*

Type of complaint

*Date of incident:*

Who are the responsible parties (who you are complaining against)? (These names can be withheld at this time if you prefer.)

Why do you think they are responsible?

Complaint description:
Enter your comments here!
*Where did this occur? (City, county, state)*

Did you sustain any injuries? If so, please describe:

Who has treated you for these injuries, and what is the approximate amount of the medical bills?

Approximate amount of other losses:

Other pertinent information:

When is the best time to contact you, and how would you prefer we contact you?

*Home phone number:*

Work phone number:

Other Phone Number:

Mailing address (street, city, state, zip):

When and how did you hear about us?

Your information is being sent directly to Burkhalter, Rayson & Associates, P.C., and by law, all communications to us are 100% confidential.

*There is no charge for us to review this inquiry and on most cases, we do not get paid unless we win.