Case Submission Form

For a free, no-obligation consultation with an experienced attorney, please submit the following response form. We will respect the confidentiality of your information to the fullest extent. Form submissions are relayed to us through our highly secure servers.

If you prefer, you may contact us at (813) 418-5256 or Toll Free: (888) 926-9529.

Tell us who you are and how we can contact you. Note: This information is strictly confidential and will not be communicated with anyone. It is necessary only for purposes of enabling us to do a conflict of interest check prior to responding to you. We cannot respond without being able to do our conflict check. ALL fields are required.

First Name

Last Name

Number, Street & Apt.

City

State

Zip

Email

Day Phone

Night Phone

State the date you were injured or when you first learned that you had been injured?

What occurred?

Where did it happen? Please type in the City, County and State where it happened:
City
State
County

Who caused the harm? Please type in the names & addresses of all the wrongdoers involved:

What damages were suffered? Describe the damage you have suffered:

Has anyone already filed a suit? Yes No

When is the best time to reach you by telephone?

Why Do You Need Help? Please provide us with a very brief overview, in 200 words or less, describing in general the subject matter of your request. You can provide more detailed information below, but for now please confine yourself to providing us with a brief statement of the general facts of your case.

When the information you have provided is complete, please press the Submit button below to send it to Cox and Associates, P.A., Attorneys At Law. Your information will be kept strictly confidential.