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Confirm the type of case causing your injuries

What type of injury is your case?

Semi-Truck Wreck Injuries

Birth Trauma, Cerebral Palsy, & Medical Malpractice

Car Wreck Injuries

Motorcycle Injuries

ATV / UTV Injuries

Aviation Injuries

Boating & Water Injuries

Burns & Electrical Injuries

Dangerous Drugs & Medical Devices

Medical Malpractice

Nursing Home Injuries

Premises Liability

Products Liability

Spinal Cord, Brain Injuries, & Amputations

Workers’ Compensation

Wrongful Death

Other Personal Injuries

We have allied attorneys in all 50 states.

Where did this occur/happen?

In what state did this occur?*

City/Town

More specifics if available.

Who was the person injured?

~Who~ was the person injured?*

Myself

Someone else

Your Name*

Your First Name Your Last Name

Your Name*

Your First Name Your Last Name

Name of Injured Person*

Their First Name Their Last Name

Their relationship to you*

Check all that apply

Did the injury involve any of the following?

Did the ~injury~ involve any of the following?*

Amputation

Failure to timely diagnose cancer

Surgery error or post-surgical error

Brain damage

Death

A need for long-term medical care, or long-term assistance

Other

Other relevant information you want to provide us

Name of at-fault medical-provider/entity if you know

~Name of at-fault medical-provider/entity if you know~

Name of hospital/clinic/facility where incident occurred

~Name of hospital/clinic/facility where incident occurred ~

Whose baby was injured?

Whose baby was injured?*

My baby

Someone else's baby

Your Name*

Your First Name Your Last Name

Your Name*

Your First Name Your Last Name

Name of injured baby's mom/parent*

Name of injured baby's mom/parent

First Name Last Name

Their relationship to you*

Select all that apply.

Did the injury result in any of the following?

Untitled*

Hospitalization of one night or longer

Surgery required

Emergency Room Visit

Referral to a Specialist

Future Medical Care Needed

Primary care visit one time or more

Physical Therapy

Chiropractor Treatment

Skin Grafts Required

Death

Other

Select all that apply

Did your baby require or have any of the following...

Untitled*

Delivery by Emergency C-section

Vaginal delivery with use of Forceps or a Vacuum

Admission to the PICU (pediatric intensive care unit) for up to 5 days

Admission to the PICU (pediatric intensive care unit) for MORE than 5 days

Had one or more seizures

Required a feeding tube or G-tube

Had a low heart rate before birth, or Fetal Distress

Have a shoulder dystocia

May have HIE (hypoxic ischemic encephalopathy)

Underwent a brain Ultrasound and/or MRI

Has Cerebral Palsy

Had low Apgar scores

Select all that apply.

Did the injury result in any of the following?

Spinal Cord Injury

Brain Injury

Amputation

Select all that apply.

Did the injury result in any of the following?

Did the injury ~result~ in any of the following?

Amputation

Failure to timely diagnose cancer

Surgery error or post-surgical error

Brain damage

Death

A need for long-term medical care, or long-term assistance

Other

Other relevant information you want to provide us

Type of Cancer

How long was the delay in diagnosis?

Less than 6 months

More than 6 months but less than a year

More than a year

Did this happen in the last 180 days?

Yes

I don't remember

Please be as specific as you can.

When did the injury happen?

Day

Month

Year

If you cannot remember the day, give us month and year.

If you cannot remember what month or year, please call our office (888)775-000

When did the birth occur?

Day

Month

Year

If you cannot remember the day, give us month and year.

If you cannot remember what month or year, please call our office (888)775-000

When did the wrongful death happen?

Day

Month

Year

If you cannot remember the day, give us month and year.

If you cannot remember what month or year, please call our office (888)775-000

Please be as specific as you can.

How did the wrongful death happen?

Untitled

Please be as specific as you can.

In summary, how did the wreck happen?

Untitled

Please be as specific as you can.

What went wrong, if you have an idea or anyone told you?

Untitled

Please be as specific as you can.

How did the injury happen?

Untitled

Please be as specific as you can.

Please describe the injury.

Untitled

Please be as specific as you can.

What type of product caused the injury?

Type your answer here...

Please be as specific as you can.

How do you believe the product was defective or unreasonably dangerous?

Type your answer here...

Please be as specific as you can.

Do you know the name of the at-fault semi-truck company?

Untitled

Please be as specific as you can.

Body of water was involved in the injury? (Name of lake, river, bay, etc.)

Body of Water

Please be as specific as you can.

Type of watercraft(s) was involved in the injury?

Untitled

Please be as specific as you can.

Tell us about those involved...

Name of at-fault medical-provider/entity if you know.

Name of hospital/clinic/facility where incident occurred.

Select all that apply.

A citation/ticket was issued to...

Please select any that apply to the incident:

Another vehicle/driver

Nobody

Unsure

I was a passenger

Please provide the employer information.

Name of Employer

Address

Employer Address & State

Street Address City State / Province / Region ZIP / Postal Code

Was the employer notified of the injury?

Yes, immediately

Yes, within 24 hours

Yes, within 30 days

Is employer/employer-insurance paying for medical care?

Yes

Select all that apply.

Has the injury resulted in...

A change in job duties/accommodations

More than 3 days off work

Tell us about the birth...

Was this your first child?

Yes

How many weeks along was the pregnancy at birth, best estimate?

Less than 36 weeks

36 – 40 weeks

More than 40 weeks

What was the baby’s birth weight, best estimate?

Deceased Information

Deceased First & Last Name

First Last

Your relationship to the deceased*

Other relevant information you want to provide us...

Untitled

Almost done- just a few more details.

Let us know the best way to reach you.

Name*

First Last

Your Phone Number*

Your Email Address*

Your Mailing Address*

Your Mailing Address City State ZIP Code

Comments

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