Your Name: *


Your Email address: *


City, State, zip code: *


Country: *


Email address: *


Phone: *


Relationship to the Victim *
Self Parent Spouse Sibling Child Other

Have you or your loved one received any settlement money from this claim? *
Yes No

Was the injury due to someone else's negligence? *
Yes No I don't know

Have you already filed a personal injury or wrongful death suit? *
Yes No

Do you have an attorney assisting you with this claim? *
Yes No

Do you want an attorney or Air Crash Consultants to contact you? *
Yes No

Did the incident occur within the past three years? *
Yes No

Date of Wrongful Death Incident: *
June 3, 2012-Dana Air Flight 992 June 2, 2012-Allied Air May 9, 2012-Sukhoi Test Flight April 20, 2012-Bhoja Airlines April 2, 2012-UtAir Aug 16, 2010 —AIRES Flight 8250 May 22 2010-India Express Flight 812 May 12 2010-Afriqiyah Airways Flight 771 Jan 25 2010-Ethiopian Airlines Flight 409 Oct 26 2009-S-Air Flight 9607 Hawker-Beech Belarus June 29 2009-Yemenia Airways Flight 626 June 01 2009-Air France Flight 447 May 20 2009-Tentara Nasional Indonesia-AU May 11 2008-Cessna Santa Cruz May 5 2009-Cessna Veracruz April 11 2009-Cessna 210M Concepcion Bolivia March 26 2009 -Arrow Cargo, Manaus March 12 2009-Cougar Sikorsky Flight 91/491 Feb 12 2009-Colgan/Continental Connection Flight 3407 Feb 7 2009-Manaus Aerotaxi Dec 15 2008-Linea Aerea Puertoriquana Nov 4 2008-Mexico City Learjet October 21 2008-Cuidad Victoria, Tamaulipas September 19, 2008-Global Exec Aviation Learjet Sept 14 2009-Aeroflot Nord Flight 821 Sept 6 2008-Kuzmino Russia Aug 30 2008-Conviasa August 24 2008-Iran Aseman/Itek Air Flight 6895 August 20 2008-Spanair Flight JK5022 July 2 2008 - UTAir Nizhnevartovsk May 30 2008-Poulin L/Cullen D Lancair Legacy May 30 2008-Taca Airlines Flight 390 May 24 2008-Island Express Helicopter Service April 3 2008-Aero JL March 1, 2008 - RUSSIA – UGRA Feb 21 2008-Santa Barbara Airlines Flight 518 Sept 16 2007-One-Two-Go Flight 269 July 17 2007-Tam Lineas Aereas Flight 3054 May 12 2007-Bell Ferry Flight Sept 29 2006-Gol Transportes Aereos Flight 1907 July 9 2006-S7 Airlines Flight 778 Nov 19, 2005-CessnaT210N Dana Point CA Nov 5 2005-Cessna 500 Sept 17 2005-Piper PA-46-310P August 14, 2005-Helios Airways Flight 522 Nov 30, 2004-Lion Air Flight 538 Oct 4, 2004-Hendrick Motorsports Beechcraft Super King Air 2004 May 17, 2004-Incair SRL Cessna T210J Other

A brief description of the situation: *


I understand that submitting this form and the information contained herein does not constitute a Consultant/Attorney/Client relationship. I understand the response to the above question is general information and I will not be charged. I understand that state laws may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter. *

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