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Accident Compensation Assesment
11 Simple Questions To Determine If Compensation May Be Owed
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1
Accident Description
*
This field is required.
Select all that apply
REAR ENDED
T-BONED (hit in the side)
HIT AND RUN
DRUNK DRIVER
HEAD ON COLLISION
CRASHED INTO STATIONARY OBJECT
DUI
Other
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2
Injuries From Accident
*
This field is required.
Select all that apply from you and others involved.
Whiplash
Concussion
Broken Bones
Lacerations and Cuts
Traumatic Brain Injuries (TBI)
Spinal Cord Injuries
Internal Injuries
Herniated Discs
Lower Back Injuries
Knee Trauma
Shoulder Injuries
Psychological Injuries
Other
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3
State Accident Took Place In
*
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Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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4
Have you hired an attorney yet?
*
This field is required.
YES
NO
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5
Did you have insurance when the accident happened?
*
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YES
NO
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6
How many vehicles were involved?
*
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1
2
3
4 or more
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7
Who was listed At-Fault?
*
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Please list the At-Fault party on the accident report.
Me or My Driver
The other driver
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8
Name
*
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First Name
Last Name
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9
Accident Date
*
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When did the accident take place?
This Week
This Month
Last Month
Less than 6 Months ago
Over 6 Months ago
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10
Home Address
If the address below is not your home please update
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11
Phone Number
*
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By my entering phone number "Submit" I agree to receive automated marketing calls/texts from Crashcare.com, its partners, and affiliates at the number provided. Consent not required for purchase. Text STOP to opt out.
Phone number
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