What date did the accident/injury occur?
Please BRIEFLY describe how your accident/injury occurred:
Where did this accident/injury occur?
Do you know the identity of the person/entity responsible for your injuries? Yes No If yes, please identify them, including contact information if known:
Were any other people or entities involved in the accident/injury? Yes No If yes, please identify all, including contact information if known:
What are the names and ages of the injured person or persons?
Please describe in detail all injuries suffered by you, or if you are submitting this information on behalf of another, all injuries they suffered:
Were emergency medical personnel called to the scene of the accident/injury? Yes No If yes, did they transport the injured person for hospital treatment? Yes No If yes, please identify the hospital or other medical facility:
Was the injured person admitted to the hospital? Yes No If yes, how long was the hospital stay?
Has there been any follow-up treatment with other health care professionals? Yes No If yes, please identify all providers by name and address (if known):
Is treatment ongoing at this time? Yes No
Has there been any improvement of the injuries since the accident/injury? Yes No
Have you missed any work or school as a result of the accident/injury? Yes No If yes, how much time?
Did any personal property get damaged/destroyed as a result of the accident/injury? Yes No If yes, please list what was damaged/destroyed:
Have you taken pictures of the injuries suffered? Yes No
Have you taken pictures of the area where the accident/injury occurred? Yes No
Have you contacted your own insurance company about this accident/injury? Yes No If yes, please BRIEFLY describe what was said:
Please identify your insurance company, including the name of anyone with whom you have spoken at that company:
Has anyone from the responsible party’s insurance company attempted to contact you? Yes No If yes, please identify the company and individual:
Have you given a statement about the accident/injury to anyone? Yes No If yes, please identify who, when, and if the statement was in writing or verbal:
Have you signed any documents related to the accident/injury? Yes No If yes, please attempt to identify what those documents were and who provided them to you:
Please BRIEFLY describe the current status of the situation, meaning what things are scheduled (medical appointments, insurance calls/meetings, etc.), if you will be missing additional work or school, etc: Are you interested in protecting your rights with a legal claim against the responsible party: Yes No
Please share any other information that you believe may be important:
Your name:
Are you the injured party? Yes No If no, please identify the injured party and your relationship to them:
Please provide us a phone number to contact you (Required):
Please provide us an email address:
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