Attorneys

What type of injuries do you have?

Automobile Accident
Wrongful death
Work Site Injury
Slip and fall
Dog bite
Other

Date of Accident

Describe how the accident occured:

If an automoile accident, Did the other driver receive a citation?

Yes
No

Amount of Property Damage:

Were any of the vehicles towed?

Yes
No

Were there any witnesses?

Yes
No

Did you go to the hospital or seek medical treatment?

Yes
No

When, where and what was done for you?

Have you been contacted by a representative from an insurance company?

Yes/No

If so, provide the following: (a) have you provided the insurance company with a recorded statement; (b) the name address and phone number of the insurance company and its representative.

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