Intake Form

If you have questions, you can call us at (212) 922-1330 during office hours Monday – Friday: 9:00am – 5:30pm EST

Step 1: Do You Have A Legal Plan?
Step 2: Fill Out the Form Below
Full Name
First Last
Plan Member's Name (if different)
First Last
Phone
Email
Which contact method do you prefer?
- Phone
- Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Current Employer
Member ID Number
Claim Number
Case Number
Preferred Language
Brief Summary of Your Legal Matter

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