| *Name: |
|
*Telephone
Number and area code: |
|
*E-Mail
Address: |
|
Have you
spoken to another attorney about your case? |
Yes
No |
If
so, has the attorney agreed to represent you? |
Yes
No |
Where
did the accident occur? (city, town or county) |
|
Who
was at fault? |
|
Did
the police write a report? |
Yes
No |
Did
the police issue any tickets? |
Yes
No |
If
"Yes", to whom did they issue the ticket? |
|
What
kind of injuries did you suffer? |
|
Were
you taken to the emergency room after the accident? |
Yes
No |
Have
you seen a doctor for your injuries? |
Yes
No |
Are
you receiving any treatment for your injuries (physical therapy,
chiropractic)? |
Yes
No |
Does
the other driver carry insurance? |
Yes
No |
Do
you carry insurance? |
Yes
No |
Was
the other vehicle a commercial vehicle or truck? |
Yes
No |
What
is the estimated amount of property damage to your vehicle? |
|
Additional
comments: |
|