San Antonio, TX(210) 871-1000 Harlingen, TX(956) 428-2102 Start Your Claim Please enable JavaScript in your browser to complete this form. - Step 1 of 5Contact InformationName *FirstMiddleLastPhone *Email *Date & Time of Incident *DateTimeNextInitial Case Assessment & Liability What exactly happened and when/where did it occur? (Determines the statute of limitations and venue). * Who do you believe is at fault for the injury? *Were there any witnesses present? *Did you take any photos of the scene or your injuries? *Select AnswerYesNoOtherIf Other, please explain *Upload Photos here * Drag & Drop Files, Choose Files to Upload You can upload up to 20 files. Did you give a statement to the insurance company? *Select AnswerYesNoDid you give a statement to the Police? *Select AnswerYesNoNextDamages and Injuries What is the nature and severity of your injuries? *Have you seen a doctor? *Select AnswerYesNoI am scheduled to see a doctorDo you have Medical Records? *Select AnswerYesNoMy doctor appointment is scheduled for *DateTimeWhat is your current prognosis, and do you require future treatment? *How has this injury impacted your daily life and ability to work? *Have you lost wages? *Select AnswerYesNoOtherIf Other, please explain *How you lost wagesHave you used sick/vacation time? *Select AnswerYesNoNextInsurance and Legal Viability Do you have uninsured/underinsured motorist coverage? *Select AnswerYesNoNot SureHas an insurance adjuster contacted you? *Select AnswerYesNoWas this a work-related injury? (Determines if workers' compensation applies) *Select AnswerYesNoHave you filed any other lawsuits related to this incident? *Select AnswerYesNoIf yes, please explain *Any other lawsuits related to this incident? do Potential company? NextPotential ChallengesDid you consume alcohol before the incident? *Select AnswerYesNoDid you consume drugs before the incident? *Select AnswerYesNoDo you have any pre-existing conditions that were aggravated? *Select AnswerYesNoIf Yes, please explain *Any pre-existing conditions that were aggravated?Could you have contributed to the accident in any way? *Select AnswerYesNoNot sureIf Yes, please explain *How you have contributed to the accident in any way? Submit Contact Jerry J. Trevino Today! Call Now : (210) 871-1000 Contact Jerry J. Trevino Today! Call Now : (210) 871-1000 San Antonio (Principal Office) 4715 Fredericksburg Rd. , Ste 507San Antonio, Texas 78229(210) 871-1000 Mon - Fri 09:00-05:00 Harlingen Office 1720 E. Harrison Ave.Harlingen, Texas 78550(956) 428-2102 Mon - Fri 09:00-05:00 FOLLOW US FollowFollowFollow Start Claim
