| Please fill in all fields marked with a * |
| General Contact Information |
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| Type of Case: |
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| *Name: |
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| Age of Injured Person: |
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| Street Address: |
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| City: |
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| State: |
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| Zip: |
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| *Email Address: |
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| Best Time to Contact: |
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| *Phone Number: |
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| Work Number: |
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| Fax Number: |
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| Type of Accident: |
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| Legal Issues |
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| Have you contacted any other lawyer about your potential claim? |
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| If yes, did the lawyer agree to represent you? |
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| Are you still being represented by the lawyer? |
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| General Incident Information |
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| On what date were you injured (mm/dd/yy)? |
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| In what city and state did the injury occur? |
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| Please briefly explain the incident that caused your injury: |
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| Who do you believe was at fault in causing your injury, and what do you believe they did wrong? |
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| Please briefly describe your injuries: |
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| Were you taken to an emergency room: |
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| If yes, which hospital: |
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| Were you admitted as an inpatient to the hospital: |
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| If yes, which hospital: |
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| Do you require physical therapy for your injuries: |
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| If yes, how often do you go to therapy: |
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| Are you still treating with a physician: |
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| What was the date of your last treatment (mm/dd/yyyy): |
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| What is the name of the physician/specialist treating you: |
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| Do you believe that any of your injuries are permanent? |
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| Employment and Earnings |
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| Are you currently collecting Workers' Compensation? |
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| Have you lost any earnings due to your injury? |
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| If yes, what amount: |
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| Have you been released by a doctor to return to work? |
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| Have you suffered any other losses because of this injury and, if so, please describe your losses: |
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| Insurance Issues |
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| Have you notified your insurance company about this claim? |
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| Has the defendant's insurance company contacted you? |
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| Auto-related Accidents Only |
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| Was a police report taken? |
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| If yes, was it taken by the state police or the local police? |
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| If local police, what is the name of the local police department? |
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| Do you have a copy of the police report? |
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| What was the damage to your vehicle? |
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| Additional Questions |
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| How did you find our website? |
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| Are there any other questions you wish to have answered? |
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