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Wrongful death intake

Legally Connect is a referral service, not a law firm. This wrongful death form collects a few details so we can connect you with an independent attorney. Fill in what you know. It is fine to leave blanks.

Before you start

  • Fields marked with * are required. Everything else is optional.
  • If you are filling this out for someone else, answer for the person who was hurt.
  • This form never asks for a Social Security number. Please do not type one anywhere on this form.
  • This form does not ask you to upload medical records, sign a contract, or give a signature.
  • Sending this form does not create an attorney-client relationship. This is a draft, and the form does not send yet.

Step 1 of 6 About you

Preferred language required

Step 2 of 6 The incident

City in Utah, if you know it.

Street, cross street, business, or other place name.

Step 3 of 6 Injuries and treatment

Describe the injuries in your own words. Write none yet if that is the case.

Where you have been treated, and what care you received. It is fine to write that you have not been treated yet.

Are you still receiving medical care?

Step 4 of 6 Insurance

Has an insurance company contacted you, or have you contacted one?

List any companies you know. Leave this blank if you do not know.

Only if you already have one. Do not enter a Social Security number.

Do you have health insurance?

Step 5 of 6 About the death

For example: spouse, child, parent, or sibling.

What kind of incident was it?
Are you the personal representative of the estate?

Step 6 of 6 Review

Questions about this form? WhatsApp us at (385) 490-6607.

Legally Connect is a referral service, not a law firm, and does not provide legal advice. Contacting us does not create an attorney-client relationship. We connect people with independent attorneys, and hiring an attorney is always your choice. Legal deadlines depend on the facts of each case, so speak with an attorney about your situation.

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Preview only: this form does not send yet.