Potential Case Submission – Other

    Your Name




    Zip/Postal Code

    Daytime Phone

    Cell Phone


    Alternate Phone


    Date of Incident Giving Rise to Claim

    Description of Claim

    How were you referred to Riley Law Firm?

    Have you consulted with any other lawyers regarding this claim? If so, please identify the lawyer(s) and state whether you have an agreement of representation with the lawyer(s).

    Has this matter previously been in litigation or arbitration? If so, please describe when and where and the current status of the matter.

    By submitting this inquiry to Riley Law Firm, you are agreeing to all of the following:

    1. You do not have a lawyer-client relationship with Riley Law Firm, and are not creating such a relationship by the submission of this form.
    2. No lawyer-client relationship will arise between Riley Law Firm, or any of its lawyers, and you until and unless a written representation agreement has been signed by both parties.
    3. Your submission of this information to Riley Law Firm was not solicited by Riley Law Firm, but rather was initiated by you after reading about Riley Law Firm on its website.
    4. You do not have a retained lawyer in connection with this matter, except as may be specifically disclosed above.

    I agree to the above.