Case Submission Form

For a free, no-obligation consultation with an experienced attorney regarding cases of personal injury and wrongful death, 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 1-800 BeltzRuth (1-800-235-8978).

Tell us who you are and how we can contact you. Note: This information is strictly confidential and will not be communicated with anyone.

First Name

Last Name

Address (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 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

What Happened?

Date of Incident:

Why Do You Need Help? Please provide us with a brief overview of what happened.

Where did it happen? Please type in the City and State.
City
State

Please press the Submit button below to send it to Beltz & Ruth, P.A.. Your information will be kept strictly confidential.

   

INTERNET SECURITY: Sending information over the Internet is not always a secure way to send information. While we will keep the information you send us over the Internet CONFIDENTIAL once it is received in our office, we cannot be assured that it will be secure while being transmitted to our office. If you have any concerns about that, please print the information above and mail it to us at:

Beltz & Ruth, P.A.
Wachovia Plaza
150 Second Avenue North, 15th Floor
St. Petersburg, FL 33701
1-800-749-3221
(727) 327-3222

THE SERVICE WE PROVIDE: When we receive the information you have provided, an attorney will evaluate the information you provided and contact you within a short time:

Obviously, the information you have sent us may not be sufficient to provide full answers to the above matters. If more information is needed, we will contact you to obtain the necessary additional information before we give you our evaluation of your potential claim.

LIMITATIONS ON OUR SERVICE:

1. The advice we provide is obviously limited by the information you provide to us.

2. Your claim may be barred by the Statutes of Limitations. These statutes provide that if a suit is not brought within a certain amount of time, the claim can never be thereafter brought. Likewise, the information you furnish may be furnished at a time so close to expiration of the statute of limitations that we do not have time to provide any help to you before the time expires. By asking for our help, you agree that we are not liable for failing to file suit on your behalf or failing to take any other action on your behalf.

3. You are not obligated to employ this firm by sending this information. Likewise, we are not obligated to accept you as a client by providing this help to you. We reserve the right to decline to represent you for any reason whatsoever. Once we have provided the limited service mentioned above, we reserve the right to refuse to become involved in further evaluation of your claim or in providing further advice.

See Terms of Use.