Date of Incident *
Was the accident your fault, or were you issued a ticket for the accident? * YesNo
Were you physically injured or in pain? * YesNo
Does anyone involved have vehicle insurance coverage? * YesNo
What types of injuries were sustained? (Please check all that apply) Muscle StrainLost LimbBrain InjuryBroken BonesSpinal Cord Injury or ParalysisLoss of Life
Did the accident cause hospitalization, medical treatment, surgery, or missed work? * YesNo
Is an attorney helping you with your case? * YesNo
State where the injury occurred: * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Estimated medical bills: * $1,000 - $4,999$5,000 - $24,999$25,000 - $100,000More than $100,000
Please describe your injuries: *
* Required Fields
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