You can always press Enter⏎ to continue
Are you the victim of an accident or an assault?
Answer these questions (all confidential) and our law firm will contact you if we can assist you. This data is protected by professional secrecy.
10
Questions
START
1
Firstname and family name
*
This field is required.
Previous
Next
Submit
Press
Enter
2
Email
*
This field is required.
exemple@exemple.com
Previous
Next
Submit
Press
Enter
3
Phone number
*
This field is required.
Previous
Next
Submit
Press
Enter
4
Where do you live in France (region)?
*
This field is required.
75
94
92
95
93
91
78
77
Abroad
Previous
Next
Submit
Press
Enter
5
You are a victim of:
*
This field is required.
a road accident
a crime
a work accident
a sports or life accident
other
Previous
Next
Submit
Press
Enter
6
Have you been hospitalized?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
7
Have you had surgery?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
8
Have you had any rehabilitation sessions?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
9
Did you have a sick leave?
*
This field is required.
Less than a month
1 to 3 month
3 to 6 month
6 to 12 month
More than 12 month
Previous
Next
Submit
Press
Enter
10
Describe your situation in a few sentences
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
11
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
11
See All
Go Back
Submit
