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West & Smith, L.L.P.
140 West Vermont AvenueP.O. Box 1140
Southern Pines, NC 28388
Phone: 910-693-3411

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?

Briefly describe the treatment you have received.

Describe the incident which resulted in your injuries?

Have you filed any claims?

Yes
No

Have you filed a police report?

Yes
No

Were there any witnesses?

Yes
No

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

Yes
No
Not sure

When and where did this incident occur?

Who are the possible at-fault persons and/or companies?


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