National Injury Internal Legal Intake and Qualification Form

1
Were you in a Auto, 18 Wheeler, Commercial Vehicle or Ride Share Accident?* This field is required.
Please Select
Please Select
Yes
No
2
Where you at fault in the accident?
Please Select
Please Select
No
Yes
3
What Type of Auto Accident
Please Select
Please Select
Auto Accident
18 Wheeler
Motorcycle
Commercial Vehicle
Ride Share
4
Name
First Name
Last Name
5
Email
example@example.com
6
Phone Number
Please enter a valid phone number.
7
When Was The Approximate Date Of The Accident? *If the Date is more than 3 years ago, we cannot take the case
Date
Month
Day
Year
8
Where was the accident?
City, State, County
9
Were you treated at the ER?
Please Select
Please Select
Yes
No
10
Have you received any other treatment since the accident?* This field is required.
Please Select
Please Select
Yes
No
11
If So, What Treatment Have You Sought?
12
Do You Know Who Provided Treatment?
13
Did You Have Insurance At The Time Of The Accident?
YESNO
14
Who is Your Insurance Provider
15
Do you know if you had uninsured motorist insurance at the time of the accident?
Please Select
Please Select
Yes
No
Not Sure
16
Confirm Qualification
Yes
Should be Empty: