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

 

After you submit your information, a lawyer will call you as soon as possible.

Please be sure to enter your name and one telephone number
* 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 lawyer will call you as soon as possible.

 

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