Accident Information
Online Interview Questionnaire

The purpose of this form is to obtain the needed information from you to better be prepared to answer your questions regarding costs of service. Please Fill out each section to the best of your ability. You may want to check the FAQ's (frequently asked questions) about accidents prior to filling this out.

Please identify and describe yourself:

*First name
*Last name
Middle initial
Date of birth
Sex Male Female

Please provide the following contact information:

Street address
(cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
*Home Phone
FAX
*E-mail

Defendants information :

First name
Last name

Middle initial
Age
Sex Male Female
DL number
Title
Employer
Street address
(cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone

Accident investigated by:


Was there a police report ?
Yes No

Enter the date of accident :

Location of Accident :



Tell us what happened (description of accident) ?

Was anyone cited ?
Yes No

Government Claim involved :
.


Your Insurance Company .



Injuries :

Medical Expenses Incurred. ?


Have you ever been in a accident before. ?
Yes No

Do you have an Attorney handling this accident ?
Yes No

Additional comments ?


WARNING:The information provided in this Web Site is general and not intended to be legal advice. Each case has its own facts which make it unique, and it is crucial that you speak to a qualified attorney before making any decisions that will affect your legal rights. This is informational only and is not intended to give you specific legal advice about your case. Also, there are no guarantees of results in any legal matter. Every Legal matter has time limits which must be observed. Failure to exercise your legal rights will result in a loss of those rights. It is crucial that you hire an experienced attorney immediately to help you. Simply contacting our office through our online interview form or via Email does not constitute hiring this office. This law firm will conduct no work on your case unless you have a signed written contract with this office to do said legal work. It is crucial that you contact an attorney immediately so that the passage of time will not result in you losing your legal rights. If you do nothing, you will lose your legal rights.

*Required fields must be completed.