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When did your accident happen?

Where did your accident happen?(on water)

Jack-up driiling
Semi-submersible
Drill Ship
Crewboat, Work boat, Etc
Construction Barge
Lift Boat
Dredge
Boat on a permanent platform
Other

Where did your accident happen?(on land)

Drilling rig
Working on railroad
Railroad crossing
Car crash-Autos
Car crash-Big Truck
Other

What injuries did you suffer?(select all that apply)

Head
Brain
Neck
Sshoulde
Arm
Hand
Mid-back
Low back
Spinal cord
Leg
Hip
Knee
Ankle
Foot
Burns
Other

What medical treatment have you received?

Hospital
Doctor
Other

Is your accident work related?

Yes
No

Please describe what happened:

Best time to contact you?

Morning
Afternoon
Evening

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

Were you injured while working?

Yes
No

What were your injuries?

Did you have a pre-existing condition?

Yes
No

Have you filed a claim?

Yes
No

If so has your claim been accepted or denied?

Accepted
Denied

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

What type of injury did you suffer?

Describe the incident:

Have you seen another attorney?

Yes
No

Have you had a second medical opinion?

Yes
No

eg. xxx-xxx-xxxx

Please explain your legal situation.