Step 1 of 7 14% DISCLAIMER: By submitting this form, you acknowledge and agree to the following: This form is treated with the utmost confidentiality, and the information you provide will not be shared with any person or authority outside the Law Office of Glenn C. McGovern. However, submitting this form does not establish an attorney-client relationship, nor does it guarantee that you will speak directly with an attorney. By submitting this form, you acknowledge and agree that no legal obligations of confidentiality beyond those required by applicable law are created. Any information you consider sensitive or privileged should not be included unless and until a formal agreement for representation has been established by you and our office. Completing this form is the fastest way to have your case evaluated. Your information will be carefully reviewed, so please be specific and concise in your responses. While we strive to respond to all inquiries within a few days, review is subject to attorney availability and may vary. If you do not hear from us or need immediate assistance, we encourage you to contact our office directly. If we determine that we can assist you, we will reach out to discuss the next steps in pursuing your case. If we are unable to accept your case, you will be notified in writing. About YouAre you contacting us for yourself or on someone else's behalf?(Required)Close Relative, alive minor childClose Relative, deceasedClose Relative, alive adultSelfPlease enter your personal information, email is preferred if you have one, we must have at least one phone number and a mailing address to contact you.Your Name(Required) First Last Your Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How Can We Reach You?We would love to chat with you. How can we get in touch?Preferred Method of ContactEmailPhoneYour Phone(Required)Your Email Address(Required) Email Address Confirm Email Address Best Time to Call You(Required)Select A Time12:00 am12:30 am1:00 am1:30 am2:00 am2:30 am3:00 am3:30 am4:00 am4:30 am5:00 am5:30 am6:00 am6:30 am7:00 am7:30 am8:00 am8:30 am9:00 am9:30 am10:00 am10:30 am11:00 am11:30 am12:00 pm12:30 pm1:00 pm1:30 pm2:00 pm2:30 pm3:00 pm3:30 pm4:00 pm4:30 pm5:00 pm5:30 pm6:00 pm6:30 pm7:00 pm7:30 pm8:00 pm8:30 pm9:00 pm9:30 pm10:00 pm10:30 pm11:00 pm11:30 pm Incident DetailsPlease select which type of incident best describes what happened to you (or the person you are contacting us on behalf of)(Required)Automobile IncidentMotorcycle IncidentMedical MalpracticePolice BrutalityJail Brutality or NeglectOther Personal InjuryWhat was the date of your incident?(Required) MM slash DD slash YYYY What Parish did this incident take place?(Required)Acadia ParishAllen ParishAscension ParishAssumption ParishAvoyelles ParishBeauregard ParishBienville ParishBossier ParishCaddo ParishCalcasieu ParishCaldwell ParishCameron ParishCatahoula ParishClaiborne ParishConcordia ParishDeSoto ParishEast Baton Rouge ParishEast Carroll ParishEast Feliciana ParishEvangeline ParishFranklin ParishGrant ParishIberia ParishIberville ParishJackson ParishJefferson ParishJefferson Davis ParishLaSalle ParishLafayette ParishLafourche ParishLincoln ParishLivingston ParishMadison ParishMorehouse ParishNatchitoches ParishOrleans ParishOuachita ParishPlaquemines ParishPointe Coupee ParishRapides ParishRed River ParishRichland ParishSabine ParishSt. Bernard ParishSt. Charles ParishSt. Helena ParishSt. James ParishSt. John The Baptist ParishSt. Landry ParishSt. Martin ParishSt. Mary ParishSt. Tammany ParishTangipahoa ParishTensas ParishTerrebonne ParishUnion ParishVermilion ParishVernon ParishWashington ParishWebster ParishWest Baton Rouge ParishWest Carroll ParishWest Feliciana ParishWinn ParishIf the incident happened in or before 2023, was there a law suit filed?(Required)YesNoIncident did not happen in or before 2023Please provide any details you have about the lawsuit:(Required)When it was filed? Where was it filed? Did an attorney file on your behalf?Are you aware of any deadline or court date?(Required)YesNoSelect the closest date.(Required) MM slash DD slash YYYY What damages did you suffer?(Required)Please select all that applies to you. Death Permanently disabled Temporarily disabled Serious physical injuries Moderate physical injuries Mental suffering confirmed by specialist Lost wages and/or material damage My records or name got damaged I do not have any of these damages What medical care did you receive or are you scheduled to receive as a result of your incident?(Required)Select the option that best describes your current medical statusSurgery and follow-up, completedStill need surgeryDoctor's visitStill seeing a doctor/still in therapyTherapy, completedI was denied proper treatment or got it lateDid not receive medical helpWho or what caused your damages?(Required)Please select the option that best describes who is is responsible and/or who can be held accountable for your damages.Police department and/or its officersSheriff's office and/or its officersJail and/or its staffDoctor/medical facility or their staffAnother motoristObstacle or man-made road condition without warningI caused the accidentHave there been any charges or convictions as a result of this incident, or is there any criminal proceeding pending?(Required)YesNoDon't know What supporting evidence do you have about the incident?(Required)Please mark all options that apply to your situation and that you know for sure exist Personal video recording Personal audio recording Personal photos Police bodycam or station video Accident report Police report Medical records Jail records I have witnesses willing to testify I do not have any evidence Please describe the major order of events that took place(Required)Please describe in 200 words or less. What do you expect us to achieve for you? Why would you want us to take your case?(Required)Please select all options that apply Compensation for lost life Compensation for loss of health and quality of life Compensation for medical bills Compensation for lost wages Compensation for loss of property/vehicle Compensation for mental suffering Compensation for future medical care Do you have any current legal representation for any matters, related or unrelated to this incident?Please select all options that apply No Yes, for a non-related issue Yes, for another personal injury matter Yes, for a criminal issue related to this incident Yes, for this same issue Name of Attorney(Required) First Last How did you hear about us?(Required)Search engine like Google or similarLegal websites like lawyers.com or AvvoI was a previous clientFriend or family memberPhone bookRecommendation from a client of yoursRecommendation from an attorneyName of former client(Required) Name of former attorney(Required)