If you've been hurt in an accident, please call 1-800-HURT-911 or complete and submit this form for a FREE evaluation.

 

After you submit your information, a HURT911® Injury Lawyer will call you.

Please be sure to enter your 1) name, 2) one telephone number, 3) state, & 4) e-mail address
* indicates a required field

First Name *
 Middle Initial       Last Name *
                  

 

(Please enter all telephone numbers but ONLY 1 is required)

Home Phone Number
1- - -
Cell Phone Number
1- - -
Office Phone Number Extension
1- - -

(Home) Street Address
  Apartment #:

(Home) City
  State *   ZIP Code 

E-mail address *

 

On what date were you injured?    Month:     Day:     Year:

Did you go to a hospital?

Please tell me what was hurt and where you have pain:

    (check off ALL that apply)

   

Neck pain? 

Back pain? 
   

Jaw pain? 

Shoulder pain ? 

    If yes: Do you have difficulty raising your arm?  Yes:   No:
   

Knee pain? 

Stitches?    

    If yes: How many stitches?

Surgery? 
   

Fracture or broken bone:   

   If yes: What was fractured: 

Torn ligament? 

Burn?  
1st degree:
2nd degree:
3rd degree:
Degree unknown - Serious 
Degree unknown - Not serious  
   

Amputation?     

    If yes: What was amputated?: 

Death?      

Please tell me what kind of accident you had or what caused you to be hurt: 

    (check off all that apply)

Vehicular & Transportation Accidents:

Automobile accident:

Motorcycle accident:

Truck accident:

Bicycle accident:

Pedestrian struck by any vehicle:

Bus accident:

Train accident:

Plane accident:

Boat accident:



Premises Accidents:

Slip or Trip & Fall accident:

Dog bite:

Elevator accident:

Escalator accident:

Assault:


Medical Malpractice, Drugs & Nursing Homes:

Birth injury:

Medical Malpractice:

Drug / Pharmaceutical injury (Vioxx, Bextra or other drug):

Nursing Home Abuse or Accident:


Other Accidents:

Construction site accident:

Industrial site accident or injury:

Chemical accident:

Fire:

Electrocution or electrical accident:

Product defect:

Lead poisoning:

Sports or skiing accident:

Other accident type:   Explain:

Comments:

Thank you for submitting your case evaluation to 1-800-HURT-911. A HURT911® Lawyer will call you as soon as possible.

 

Please Wait For Confirmation Page!

DISCLAIMER This is an advertisement. The material and information contained on these pages and on any pages linked from these pages are intended to provide general information only and not legal advice. You should consult with a lawyer licensed to practice in your jurisdiction before relying upon any of the information presented here. You are advised that the act of sending e-mail to or downloading information from this website does not create an attorney-client relationship. While we greatly appreciate your submission, due to many different reasons email can fail to be delivered, we cannot guarantee a response to e-mail. Also, remember that electronic mail on the internet is not secure and that you should avoid including sensitive, confidential or damaging information in unencrypted messages. Accordingly, we strongly encourage those seeking criminal defense representation to contact us by telephone at 1-800-HURT-911. Persons accessing this site are encouraged to seek independent counsel for advice regarding their individual legal issues if you submit your information and do not get a response within 24 hours.

This Personal Injury Call Analysis(sm) form and Serious Injury Alerts® are protected by copyright, service marks and patents pending, owned by Philip L. Franckel, Esq.