Case Submission Form

For a FREE consultation with an experienced attorney regarding cases of personal injury, 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 (949) 440-0860, or Toll-Free (800) 440-3554.

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.

First Name

Last Name

Number, Street & Apt.

City

State

Zip

Email

Day Phone

Night Phone

Please provide a brief personal background of the person needing assistance. Many times we are contacted by someone other than the person in need of help, such as a parent on behalf of a child, or wife on behalf of a husband. Please provide the following information on behalf of the person who needs assistance.

The following information is for myself: Yes No

If "No" my relationship to the following person is:

First Name

Last Name

Age

Occupation

For how long

Current or last employed

City and State where last employed

Highest grade completed

Schools/College attended

Degrees

Year degree granted

Special training or experience in

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, injury and damages.

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?

When the information you have provided is complete, please press the Submit button below to send it to The Law Offices of Charles A. Pernice. Your information will be kept strictly confidential.

The Law Offices of Charles Pernice handles the following types of cases: Lemon Law, Automobile Fraud, Consumer Fraud, Credit Damage, ID Theft, Investor Claims, Employment Law, Mediation & Personal Injury including Automobile Accidents, Spinal Cord Injuries, Traumatic Brain Injuries, Medical Malpractice, Wrongful Death, Insurance Bad Faith, Nursing Home Abuse, Airplane Accidents, Dog Bites, Drunk Driving Injuries, Large Truck Accidents, Motorcycle Accidents, School Bus Accidents, Slip and Fall Accidents.

The Law Offices of Charles Pernice serves the following areas: California, Southern California, Imperial County, San Diego County, Riverside County, Ventura County, Orange County, Los Angeles County, San Bernardino County, Anaheim, Chula Vista, Glendale, Huntington Beach, Long Beach, Los Angeles, Riverside, San Diego, Santa Ana, San Bernardino, Irvine, Burbank, Corona, Costa Mesa, Downey, East Los Angeles, El Monte, Escondido, Fontana, Fullerton, Garden Grove, Inglewood, Lancaster, Moreno Valley, Norwalk, Oceanside, Ontario, Orange, Oxnard, Palmdale, Pasadena, Pomona, Rancho Cucamonga, Santa Clarita, Simi Valley, South Gate, Thousand Oaks, Torrance, Ventura, Victorville, West Covina

The legal information offered by The Law Office of Charles Pernice and contained herein, regarding California legal statutes and California claimants' rights, is general in scope. No legal attorney / client relationship with our attorneys is hereby formed nor is the information herein intended as formal legal advice. Please contact a California lawyer regarding your specific inquiry.See Terms of Use.