- Step 1 of 5

Contact Information

Name *

First

Middle

Last

Phone *

Email *

Date & Time of Incident *

Date

Time

Initial 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? *

If 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? *

Did you give a statement to the Police? *

Damages and Injuries

What is the nature and severity of your injuries? *

Have you seen a doctor? *

Do you have Medical Records? *

My doctor appointment is scheduled for *

Date

Time

What 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? *

If Other, please explain *

How you lost wages

Have you used sick/vacation time? *

Insurance and Legal Viability

Do you have uninsured/underinsured motorist coverage? *

Has an insurance adjuster contacted you? *

or company? you

Was this a work-related injury? (Determines if workers' compensation applies) *

Have you filed any other lawsuits related to this incident? *

If yes, please explain *

Any other lawsuits related to this incident?

Potential Challenges

Did you consume alcohol before the incident? *

Did you consume drugs before the incident? *

Do you have any pre-existing conditions that were aggravated? *

If Yes, please explain *

Any pre-existing conditions that were aggravated?

Could you have contributed to the accident in any way? *

If Yes, please explain *

How you have contributed to the accident in any way?