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Jury Verdicts

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Law Office of Richard W. Hay
203 W. Columbia Street
P.O. Box 1124
Somerset, KY 42502

Phone: (606) 679-2214

Intake Form

Questionnaire

[Note all fields are required]
Date:
Name:
Married: Yes No     Minor children: Yes No
Telephone:
    home
    Work
    Other
Mailing Address:
City:
State:
Zip:
Email Address:

Place of employment:

Occupation:

If disabled, what is the nature of your disability? If none, type "none".

Type of potential claim:

  • car wreck/ motor vehicle accident
  • defective product
  • medical negligence
  • premises liability
  • other

Date of Incident:

Briefly tell us about your potential claim: