4615 Sherman Street

Houston, Texas 77011

Ph: (713) 804-9118

Fax: (346) 585-0121

Email: ngiles@pinnaclelawgrouphtx.com

Thank you so much for contacting the Pinnacle HTX Law Group PLLC! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security numbers are most often used to positively identify parties. Most courts require Social Security numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in court orders
in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you! To return to the website, please click here.

PERSONAL INFORMATION

Contact information: Client

Prefix

First name *

Middle name

Last name *

Date of birth

Emails

Email Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Are you over 65 years of age?

Yes

Are you over 18 years old?

Yes

Parent / Guardian #1 Full Name Parent / Guardian #1 Address Parent / Guardian #1 City/State/Zip Parent / Guardian #1 Phone Parent / Guardian #1 Email Parent / Guardian Relationship to Minor?

Enter your relationship to the minor (e.g., “Mother,” “Father,” “Legal Guardian,” “Managing Conservator,” or “Next Friend”). If you are not the parent, specify your legal authority in parentheses (e.g., “Legal Guardian (court-appointed)”, "Next Friend (Temporary Custody)").

Driver's License / Identification State

Please identify the State of your driver's license or identification card (e.g. Texas, Arizona, California, etc.)

Driver's License / State ID No.

Client's driver's license or state identification number

Social Security #

Military Service?

Yes

Are you married?

Yes

Do you have children for whom you pay child support?

Yes

Are you employed?

Yes

Select primary social media platform

Provide your primary Social Media Handle

ACCIDENT/INCIDENT INFORMATION

Please answer the questions below regarding how the accident occurred, when and where it took place, and who was involved. Provide information to the greatest extent possible and to the best of your ability. Even if you do not have all the answers, include as much detail as you can recall, as this information helps our office fully evaluate your claim.

Accident Location

City / County of Incident

Date of Incident

What were total number of vehicles involved in the accident

Answer question if you were involved in multi-vehicle accident

Were you the driver or a passenger at the time of accident?

Were there any passengers in the vehicle other than yourself at the time of the accident?

None

Passenger #1 Full Name Passenger #1 City/State/Zip Passenger #1 Address Passenger #1 Phone Number Passenger #1 Email Passenger #2 Full Name Passenger #2 Address Passenger #2 City/State/Zip Passenger #2 Phone Number Passenger #2 Email

If known, was a commercial / rideshare / government vehicle involved?

Commercial vehicleRideshare vehicleGovernment vehicleNone of the above

Describe the accident and/or what occurred?

Were there any witnesses at the scene of the accident?

Identify only witnesses other than passengers or other drivers involved in accident (if applicable).

Yes

Do you have any photos of the scene of the accident?

Yes

Upload Photo #1

Add attachment

Upload Photo #2

Add attachment

Upload Photo #3

Add attachment

Upload Photo #4

Add attachment

Upload Photo #5

Add attachment

Upload Photo #6

Add attachment

Was an accident or incident report filed?

Yes

Brief description of injuries?

AUTOMOBILE INFORMATION

Please provide complete information regarding your vehicle, including ownership, registration, and insurance details, as well as the nature and extent of any property damage sustained in the collision. Accurate and thorough responses will assist our office in verifying insurance coverage, assessing liability, and coordinating the property damage portion of your claim.

Make, model and year of your vehicle involved in the accident

License plate number of your vehicle or vehicle your traveled in at time of accident?

VIN number of your vehicle

Are you the owner of the vehicle involved?

Yes

If you are not the vehicle owner, does owner of vehicle have insurance?

If you answered yes to previous question, please skip.

Yes

Do you have auto insurance?

Answer the following question if you are the owner of vehicle.

Yes

Was a rental car used / do you need a rental?

Yes

Claim number (if known/available)

If you have filed a claim with your own insurance or other party's, provide claim number here.

Brief description of damage caused to your vehicle?

OTHER PARTY CONTACT INFORMATION

Complete the other driver’s contact information below. Include as many details as possible, such as their full name, date of birth, phone number, and address. If you do not have all of the information, provide whatever details you recall or have available.

Do you know the other driver's contact information

Yes

Do you have picture of copy of other party's drivers license?

Yes

Did the other party have automobile insurance?

Yes

Unsure

Do you know the make, model and year of other party's vehicle?

Yes

Do you know the license plate number of other party's vehicle?

Yes

Did the other party have passengers?

Yes

If known, briefly describe damage to other party's vehicle

ADDITIONAL INFORMATION

Any additional Information you think would be helpful

EMERGENCY CONTACT

Please provide emergency contact details, including the individual’s full name, relationship to you, primary phone number, and email (if available) in the event we need to reach someone on your behalf.

Contact information: Emergency Contact

Prefix

First name *

Middle name

Last name *

Emails

Email Address *

Type

Add email

Phone numbers

Phone number

Type

Add phone number

PERSONAL INFORMATION

Contact information: Client

Are you over 65 years of age?

Are you over 18 years old?

Driver's License / Identification State

Driver's License / State ID No.

Social Security #

Military Service?

Are you married?

Do you have children for whom you pay child support?

Are you employed?

Select primary social media platform

Provide your primary Social Media Handle

ACCIDENT/INCIDENT INFORMATION

Accident Location

City / County of Incident

Date of Incident

What were total number of vehicles involved in the accident

Were you the driver or a passenger at the time of accident?

Were there any passengers in the vehicle other than yourself at the time of the accident?

If known, was a commercial / rideshare / government vehicle involved?

Describe the accident and/or what occurred?

Were there any witnesses at the scene of the accident?

Do you have any photos of the scene of the accident?

Was an accident or incident report filed?

Brief description of injuries?

AUTOMOBILE INFORMATION

Make, model and year of your vehicle involved in the accident

License plate number of your vehicle or vehicle your traveled in at time of accident?

VIN number of your vehicle

Are you the owner of the vehicle involved?

If you are not the vehicle owner, does owner of vehicle have insurance?

Do you have auto insurance?

Was a rental car used / do you need a rental?

Claim number (if known/available)

Brief description of damage caused to your vehicle?

OTHER PARTY CONTACT INFORMATION

Do you know the other driver's contact information

Do you have picture of copy of other party's drivers license?

Did the other party have automobile insurance?

Do you know the make, model and year of other party's vehicle?

Do you know the license plate number of other party's vehicle?

Did the other party have passengers?

If known, briefly describe damage to other party's vehicle

ADDITIONAL INFORMATION

Any additional Information you think would be helpful

EMERGENCY CONTACT

Contact information: Emergency Contact

What is emergency contact's relationship to client?

REFERRAL & MARKETING SOURCE

How did you hear about our law firm?