If you believe that you or someone close to you may have a personal injury claim, please fill out the following questionnaire. By submitting the information below, you will enable the attorneys at Napoli Bern Ripka, LLP to evaluate your case based on its merits. Please be as complete as possible in the information you provide. If you would like to contact Napoli Bern Ripka, LLP for reasons other than a possible personal injury or medical malpractice suit, please fill out the form on this page as well. There is no charge for this evaluation GENERAL CONTACT INFORMATION: First Name: Last Name: Address:   City: State: Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Home Phone: Work Phone: Email Address: What method would you prefer we use to contact you? E-mail Phone Fax What time of day would you like us to call? Morning Afternoon Evening N/A GENERAL INCIDENT INFORMATION: On what date were you injured (00/00/00)? / / In what city and state did the injury occur? Please briefly explain the incident that caused your injury: Please briefly describe your injuries: Do you believe that any of your injuries are permanent? Yes No Not Sure IMPORTANT LEGAL DISCLAIMERS: Yes No - I agree that this matter may be referred to an attorney in my area who may contact me. Yes No - I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. Yes - I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. By Clicking the appropriate box below, I agree to:  EMAIL DIRECTORY Paul J. Napoli Senior Partner Marc Jay Bern Senior Partner Alan S. Ripka Senior Partner   Ann Corcoran Of Counsel Brian Guillorn Of Counsel Noble McIntyre Of Counsel Jeremy Thurman Of Counsel Richard Weiss Of Counsel   W. Steven Berman Associate Christian Coppinger Associate William J. Dubanevich Associate Robert Gitelman Associate Sarah Green Associate Christopher R. Lopalo Associate Denise A. Rubin Associate Marina Zapantis Associate

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