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Personal Injury Intake Form

Tell Us About Your Personal Injury Case

Life for an injury victim often times becomes much more difficult after the injury, and the extent of one's injuries is not always clear until days or even months after the incident occurs. Not only does the victim suffer physically (and possibly mentally) as a result of an injury, but now the victim or a representative must deal with doctors, insurance companies, and possibly attorneys. Each of the parties involved will require the victim or a representative to provide them with documentation. If you are an injury victim and planning to file a claim, your attorney will ask a number of detailed questions; so preparing early will make the process much easier (while helping you remember key details). Please note that completion of this form does not bind legal representation. Upon completion of this confidential form, you will be contacted by an attorney to discuss your case.
  • List the names, addresses, and telephone numbers of all insurance companies that may be involved (including, as applicable, automobile insurer, health insurer, disability insurer, homeowner's insurer, etc.). | Health Insurance Company: | Automobile Insurance Company: | Local Insurance Agent (if any):
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