SUBMIT A CLAIM

Use of the following claim form is a free service of Scott Cole & Associates. Submission of claim information through use of this form allows us to efficiently exchange information with you and answer your specific legal questions. We will not disclose this information or contact the company without talking to you first.

If you believe you have a claim or concern that you would like us to evaluate at no cost or obligation to you, please use the form below. Only a few fields are required, but providing as much information as possible better helps us to serve you.

The fields marked * are required fields.

* First Name:   * Last Name:
* E-mail: * Confirm E-mail:
  Address:
  City:   State:
  Zip:
  Day time Phone:   Evening Phone:
 
 
* Company at issue:
 
  Claim date:
  Job title:
  Describe the problem:
* Which category does your
  complaint best fit into?:
  Have you ever contacted
  a lawyer about this?:
Yes      No

  Are you currently working
  with a lawyer on this?:
Yes      No

  How did you learn
  about us?:

By submitting this form:
       You confirm that the information you provided is true and not given for the purpose of harassment.
     
       You understand that using this web site in no way implies our acceptance of an attorney-client relationship, but that we may contact you to confidentially discuss your complaint.
     
       You understand that use of the information you submit on this site is governed by our privacy policy.

* I have read and agree to the above and the Terms and Conditions.