Form cover
Page 1 of 3

Injured in a Car Accident? Start With a Case Review.

Answer a few questions to see if your accident meets the initial criteria used by law firms for further review.


Were you injured in a car accident?

Were you injured in a car accident?
A
B

When did the accident occur?

When did the accident occur?
A
B
C
D

Did you receive medical treatment for your injuries? (Select the highest level of treatment you have received)

For example, if you visited the ER and later went to physical therapy, select ‘ER/Hospital.'
Did you receive medical treatment for your injuries? (Select the highest level of treatment you have received)
A
B
C
D
E

Who was at fault for the accident?

Who was at fault for the accident?
A
B
C

Was a police report or insurance claim filed?

Was a police report or insurance claim filed?
A
B
C
D

Are you currently represented by a lawyer for this accident?

Are you currently represented by a lawyer for this accident?
A
B

What injuries did you suffer?

What injuries did you suffer?
A
B
C
D
E
F

ZIP code where the accident occurred (If unknown, what city?)

First Name

Last Name

Phone Number

Email Address

Would you like to speak with a lawyer as soon as possible?

Would you like to speak with a lawyer as soon as possible?
A
B
C