New Client Intake Form | Gelch & Associates, P.A. 24/7TAP TO CALL Attorneys Gary Gelch Omar Cardenas George Palaidis Anna Lane Martin Mehan Practice Areas Negligence Auto Accidents Boating & Cruise Ship Accidents Brain Injuries Burn Injuries Animal Attacks Negligent Security Motorcycle Accidents Slip & Fall Accidents Trucking & Bus Accidents Personal Injury Criminal Defense Theft & Trespassing Drug Charges Battery & Other Violent Crimes DUI / DWI White Collar Crimes Other Criminal Charges Malpractice & Liability Medical Malpractice Nursing Home Abuse & Negligence Defective Products Drug Recalls Employment & Insurance Workers Compensation Unpaid Overtime Insurance Denials & Disputes Storm Damage Insurance Claims Offices Plantation, FL Naples, FL Fort Myers, FL Jupiter, FL Orlando, FL Jacksonville, FL Birmingham, AL Chicago, IL Contact Español English 866-780-4878 New Client Intake Form All fields marked with a * are required. *In which state is your case located?: Choose a state Florida Alabama Illinois *First Name: Middle Initial: *Last Name: Suffix: *Home Address: *City: *State: *ZIP Code: *Cell Phone: Home Phone: Work Phone: Email Address: *Date Of Birth (Month): *Date Of Birth (Day): *Date Of Birth (Year): Social Security Number (Optional): How did you hear about us? Date Of Accident: Description Of Accident: Location Of Accident: Your Claim Number: Other Party's Claim Number: Description Of Injuries: Upload files Processing dropped files... Close No Yes Cancel Ok We have received your information.