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Heiligman & Mogul, P.C.
135 S. 19th St., Suite 200
Philadelphia, PA 19103
Phone: 866-626-3073

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?

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

eg. xxx-xxx-xxxx

Please explain your legal situation.


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