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

 

After you submit your information, Attorney Robert Plevy will call you as soon as possible.

Please be sure to enter your name and one telephone number
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First Name *
 Middle Initial       Last Name *
                  

 

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

Home Phone Number
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Cell Phone Number
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Office Phone Number Extension
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(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/Incidents:

Construction site accident:

Industrial or Factory site accident:

Chemical accident:

Fire:

Electrocution or electrical accident:

Product defect:

Lead poisoning:

Sports or skiing accident:

Sexual Harassment at work/office:

Employment Discrimination:

Other accident type:   Explain:

Comments:

Thank you for submitting your case evaluation to 1-800-HURT-911. Attorney Robert Plevy will call you as soon as possible.

 

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Submission of your information for case evaluation by submission of this case evaluation form does not create an attorney client relationship. Consultation is absolutely free of charge, and does not create an attorney client relationship. An attorney client relationship can only be created by the mutual agreement of both you and a lawyer set forth in a written Attorney Retainer Agreement, signed by both a lawyer and you. No guarantees or warranties of any kind are made by 1-800-HURT-911, Inc., either with regard to the quality of the performance of the lawyer, or with regard to the result that may be obtained. It is the prospective client's responsibility to independently inquire and confirm the credentials and expertise of all attorneys whom he or she would interview and evaluate those that may be important to the prospective client. 1-800-HURT-911, Inc. does not undertake, under any circumstances, to supervise, control or take any other role in the prosecution of litigation, or any responsibility therefore.

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.