Attorneys

What type of injuries do you have?

Auto/Motor Vehicle Accident
Slip and fall
Dog bite
Railroad accident
Wrongful death
Hurt on the job
Other

What is the extent of your injuries?

Have you seen a doctor?

Yes
No

What are your medical bills?

Have you filed any claims?

Yes
No

Have you filed a police report?

Yes
No

Were there any witnesses?

Yes
No

Do you have insurance that covers you for this type of incident?

Yes
No
Not Sure

Do other involved parties have insurance that covers this type of incident?

Yes
No
Not sure

How was the victim related to you?

When did the incident occur?

Select Within last 30 days 1-3 months ago 4-6 months ago 7-12 months ago More than 12 months ago

Were criminal charges filed?

Yes
No
Not Sure

Were there any witnesses?

Yes
No
Not Sure

Was there a doctor involved?

Yes
No
Not Sure

If so what were medical bills?

Please explain the circumstances

Do you have any previous drunk driving convictions?

Yes
No

If yes how many?

Select 1 2 more than 2

Were you involved in an accident?

Yes
No

If yes was anyone hurt?

Yes
No

Were any of the following field sobriety tests performed (check all that apply)?

Breathalizer
Alphabet
Counting
Balance
Nose

Were you arrested at the scene?

Yes
No

What type of injuries do you have?

Auto/Motor Vehicle Accident
Slip and fall
Dog bite
Railroad accident
Wrongful death
Hurt on the job
Other

What is the extent of your injuries?

Have you seen a doctor?

Yes
No

What are your medical bills?

Have you filed any claims?

Yes
No

Have you filed a police report?

Yes
No

Were there any witnesses?

Yes
No

Do you have insurance that covers you for this type of incident?

Yes
No
Not Sure

Do other involved parties have insurance that covers this type of incident?

Yes
No
Not sure

eg. xxx-xxx-xxxx

Please explain your legal situation.