General Contact Information:
Your Name:
Age of Injured Person:
Street Address:
City:
State:
Zip:
E-mail Address:
Best time to contact you:
Select:
Anytime 9a-5p
8am-12noon
12noon-4pm
4pm-8pm
After 8pm
Phone Number:
(Area)
Work Number:
Fax Number:
Type of Accident:
Select:
Alcohol-Related Accidents
Automobile Accidents
Boating Accidents
Construction/Industrial Accidents
Cruise Ship Accidents
Defective Products
Defective Roads
Defective Seat Belts
Dog Bites
Head/Spinal Cord Injuries
Medical Mistakes
Motorcycle Accidents
Negligence
Nursing Home Injuries
Slips and Falls
Swimming Pool Accidents
Work-Related Accidents
Wrongful Death
Legal Issues:
Have you contacted any other lawyer about your potential claim?
Select:
Yes
No
N/A
If you answered yes to the previous question:
Select:
Yes
No
N/A
Are you still being represented by the lawyer?
Select:
Yes
No
N/A
General Incident Information:
On what date were you injured (mm/dd/yyyy)?:
In what city and state did the injury occur?
Please briefly explain the incident that caused your injury:
Who do you believe was at fault in causing your injury, and what do you believe they did wrong?
Please briefly describe your injuries:
Were you taken to an emergency room:
Select:
Yes
No
N/A
If yes, which hospital:
Were you admitted as an inpatient to the hospital:
Select:
Yes
No
N/A
If yes, which hospital:
How many days were you an inpatient:
Do you require physical therapy for your injuries:
Select:
Yes
No
N/A
If yes, how often do you go to therapy:
Are you still treating with a physician:
Select:
Yes
No
N/A
What was the date of your last treatment (mm/dd/yyyy)?:
What is the name of the physician and/or specialist treating you for your injuries:
Do you believe that any of your injuries are permanent?
Select:
Yes
No
Not Sure
Employment and Earnings:
Are you currently collecting Workers' Compensation?
Select:
Yes
No
Have you lost any earnings due to injury?
Select:
Yes
No
Have you been released by a doctor to return to work?
Select:
Yes
No
N/A
Do you believe you are too injured to return to work?
Select:
Yes
No
N/A
Have you suffered any other losses (home, vehicles, etc...) because of this injury and, if so, please describe your losses:
Insurance Issues:
Have you notified your insurance company about this claim?
Select:
Yes
No
N/A
Has the defendant's insurance company contacted you?
Select:
Yes
No
N/A
For automobile-related accidents only:
Was a police report taken?
Select:
Yes
No
N/A
If yes, was it taken by the state police or the local police?
Select:
State Police
Local Police
If local police, what is the name of the local police department:
Do you have a copy of the police report?
Select:
Yes
No
N/A
What was the damage to your vehicle?
Select:
None
Mild
Moderate
Total
How did you find our website:
Television Ad:
Radio Ad:
Newspaper Ad:
Billboards:
Referred by a Friend:
Search Engine:
Other:
Any Additional Questions?
Are there any other questions you wish to have answered?
