Customer Evaluation Form

For a free evaluation of your personal injury claim, please complete and submit the form below:

Your Name:*
Street Address:*
City / Township:*
State / Province:*
Zip Code:*
Daytime Number:
Evening Number:
Fax Number:
E-mail Address:*
Location of accident:
Date of accident:
Is there a police report?
If so, do you have a copy?
Describe the accident (include what the other party did wrong to cause the accident)
If an automobile accident, estimate of the cost to repair property damage:
Other party's insurance company:
Your insurance company:
Your health insurance:
Were you seen in a hospital emergency room?
Were you hospitalized?
Have you seen a doctor for your injuries?
Are you still under a doctor's care as a result of the accident?
Total medical bills:
How much time have you lost from work or school?
How did you hear about The Accidental Lawyer?