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 own a home?

Yes
No

What is your marital status?

Select Married Divorced Single

How many children do you have?

Select 0 1 2 3 more than three

What is your age?

Do you currently have an estate plan?

Yes
No

What types of services would you like (check all that apply)?

Asset Protection
Power of attorney
Will/General Advice
Living Will
Health Care Power of Attorney
Trust
other

Do you own a business?

Yes
No

If so how many years have you owned your business?

What type of business entity is this?

Select Limited Liability Corporation Corporation Partnership Sole proprietorship other

How many employees do you have?

Select 1 thru 10 11 thru 25 more than 25

If you do not currently own a business are you planning to start one?

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.

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