Who was the person injured?

Me

Someone else

Name*

First Name Last Name

Your Name*

First Name Last Name

Name of Person Injured*

First Name Last Name

Their relationship to you:*

Contact Information

Your best contact phone number:*

Your email address:*

Your mailing address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Where did the injury occur?

State:*

City:

(if the crash occurred away from a city, nearest big city)

More specifics if available:

Type of Injury

Type of Injury:

Death

Non-death

Please be as specific as you can.

When did the injury occur (earliest possible date)?

Year

Month

Day

I’m not sure of the month and/or day, but the season was:

Summer

Fall

Winter

Spring

How did the injury happen is there any idea of what went wrong?

(FYI – 400 character limit)

Type of aircraft, if you know:

Company owner of the aircraft, if you know:

Other relevant information you want to provide us:

(FYI – 400 character limit)

If for some reason you don’t hear from us within 1 business day, please call us directly at 888-775-0000. Thank you again.

Thank you for submitting. A Dr. Brad Bradshaw Law Firm staff member will be calling you shortly.

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