PERSONAL INJURY
INFORMATION FOR INITIAL INTERVIEW
***This information will help our attorneys determine if you a have valid Personal Injury case***
Your Full Name:
Your E-mail address:
Your Phone Number:
Your Address:
Did you get Hurt:
Yes
No
Did you get treatment:
Yes
No
Body Parts Injured:
Date of Accident:
Enter Time of Accident:
AM
PM
Exact Location of Incident:
City where Accident took place:
Who's Fault was it?
If someone else's fault, Why?:
Did the party at fault have insurance?:
Yes
No
Name of their Insurance Company:
Do you have insurance?:
Yes
No
What type of Insurance Coverage do you have?
What is the Name of your Insurance Company?:
Prior Claim/Accident History:
Have you ever made any other Personal Injury Claims?:
NO
Yes
If yes, Date and Type, and Body Parts injured in Each one:
Have you ever made any Workers' Compensation Cases?:
NO
Yes
If yes, Dates of Each one, and Body parts injured:
Other than the Prior Personal Injury Cases And/Or Workers' Comp Cases,
If any, Have you ever Injured the Same Body Parts that are injured from this accident:
NO
Yes
If yes, When:
*
Please allow 24 hours to contacted by our office