Intake Form

1

Unique ID

2

What best describes your situation?* This field is required.We'll be able to route your case to a licensed attorney that specializes in your specific situation.

I was hit by another vehicle

I slipped, tripped or fell

I was harmed due to medical negligence

I got injured at work

A dog or domesticated animal attacked me

None of the Above / Not Sure / Other

3

Date of IncidentTry your best to remember around what time it happened.

Date

4

Were you at fault for the accident?

YESNO

5

Briefly Describe What Happened

6

Were you physically injured?* This field is required.Injuries don't often appear at the time of an accident. They can appear later on. That is why medical attention is recommended as soon as an accident occurs.

YESNO

7

What is the primary type of injury?* This field is required.We'll be able to route your case to a licensed attorney that specializes in your specific situation.

Back or Neck Pain

Head Injury

Broken Bones

Bites / Cuts / Bruises

Other

8

If you were injured, did you receive medical attention?

YESNO

9

Were you insured at the time of the accident?* This field is required.

YESNO

10

If yes, do you know if your policy includes Uninsured/Underinsured Motorist (UIM) coverage?Tip: This is usually listed on your insurance declaration page.

Yes

No

Not Sure

11

Have you ever signed up with a law firm to help you with this case?* This field is required.

YESNO

12

Email* This field is required.Please enter a valid email — we’ll use it to send important next steps to connect you with a licensed attorney.

example@example.com

13

Name* This field is required.

First Name

Last Name

14

Phone Number* This field is required.Please enter a valid phone number — we’ll use it to send important next steps to connect you with a licensed attorney.

Please enter a valid phone number.

15

Terms and Conditions* This field is required.