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DID YOU SUFFER MAJOR INJURY IN A TRAFFIC ACCIDENT?

   



 
Tell us about your traffic accident to see if we can help
 
 

NAME *
EMAIL *
PHONE NUMBER *
ACCIDENT LOCATION *
CASE TYPE *
ACCIDENT DATE *
Is there a dispute as to who is liable for the accident?
Describe your diagnosed injuries and cost of medical treatment.

Add More Detail About Your Case:

Brief description of the accident:

How soon after the accident did you receive treatment?

What are you medical costs to date?

Do you have health insurance? If so, describe:

If applicable, how much was the damage to your vehicle?

Your auto insurance carrier (if applicable):

The other party's auto insurance:

Is there a Police Report?
YesNo

If so, which agency created it?

If so, what is the report number?

If not, do you have any supporting witnesses?

Do you have a copy of it?
YesNo

Do you have any preexisting injuries our conditions? If so, explain.

Did you suffer a loss of earnings due to the accident? If so, please explain:

Anything else we should know about your case to better evaluate it?

I have read and understand the disclaimer.


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