Personal Injury Case Evaluation

Describe your claim:
Who was injured?
If other, please describe:
If other, please provide the persons name:
When was the date of the incident?
Where did the incident occur?
Was this location the injured person's:
If "Workplace," did the injury occur as a result of employment activities?
If "Other," was this a road accident?
If no, did the injury occur on another's property?
If yes, who owns the property?
How did the injury happen?
What were the surrounding circumstances (weather, lighting, slipperiness, other)?
Were there witnesses to the injury?
If yes, what are their names/contact information?
Was there a police report?
Did the injured person receive medical treatment?
If yes, provide dates, locations, provider names, and details:
Is the injured person still receiving treatment?
Was the injured person killed as a result of the accident?
If yes, what was the date of his or her death?
Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:
Describe other losses resulting from the injury (lost wages, damaged property, other):
Where did you hear about this website?
Best way to contact you:
Best time to contact you:
First Name:
Last Name:
Phone:
Email:
Address 1:
Address 2:
City:
State:
Zip:

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Office Locations

Alabama Law Office	Florida Law Office
51 St. Joseph Street	216 Palafox Place
P.O. Box 894	P.O. Box 12305
Mobile, AL 36601	Pensacola, FL 32502

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