CONTACT INFORMATION Name * First Name Last Name Law Firm Name Office Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Website Link BAR CREDENTIALS Florida Bar Number Years Admitted to Practice Are you currently in good standing with the Florida Bar? Yes No Do you carry professional liability insurance? Yes No Practice Details Primary Practice Areas (Check all that apply) Auto Accidents Personal Injury Wrongful Death Premises Liability Medical Malpractice Other: Counties You Serve Miami-Dade Broward Palm Beach Other: Preferred Case Types Soft Tissue Injuries Catastrophic Injuries Property Damage Only All of the Above Referral Preferences Preferred Contact Method Email Phone CRM Portal Access Are you open to emergency referrals (e.g., hospital visits)? Yes No Do you offer free consultations? Yes No Do you accept cases on contingency? Yes No Compliance & Consent I certify that I am a licensed attorney in good standing with The Florida Bar I agree to comply with Rule 4-7.22 and all applicable advertising and referral regulations I authorize Your Florida Accident to refer clients to me based on the information provided Today's Date MM DD YYYY Thank you! Join Our Attorney Network
