Hey there! What's your name?

Full Name *

Email *

Phone *

Please complete the following form with detailed information to help us evaluate and understand your situation thoroughly. This will enable us to provide the most appropriate support for your needs. Your responses will be treated with strict confidentiality.

Please provide accurate and detailed information about the victim's injuries and their impact on their ability to perform daily activities. "seriously injured" refers to bodily injury that involves substantial risk of death, protracted and obvious disfigurement, or protracted loss or impairment of the function of a bodily member or organ or mental faculty. It also includes any injury, other than a fatal injury, which prevents the injured person from walking, driving, or normally continuing the activities they could perform before the injury occurred. Examples of such injuries may include severe lacerations, broken or distorted limbs, skull or chest injuries, abdominal injuries, unconsciousness at or when taken from the crash scene, and being unable to leave the crash scene without assistance. However, it does not include momentary unconsciousness.

Understood, Let's Continue.

What's Your Address?

Address *

City *

State *

Postal code *

What are the accident victim's details?

Accident Victim's Full Name *

Accident Victim's Age *

Accident Victim's Gender *

Accident Victim's Address (At Time of Accident) [City, State, ZIP Code] *

What was the Date, Time, and Location of the accident?

Date of Accident *

Time of Accident *

Address or Intersection of Accident (Including City, State, Zip Code) *

Brief Description of Accident *

Please tell us a little about the injuries.

Was The Victim: *

Deceased

Seriously Injured

What are the nature of the injuries? (If "Seriously Injured" is selected)

What is their current medical condition? (If "Seriously Injured" is selected)

Please tell us a little about the medical treatment.

Name of Hospital or Medical Facility Treating the Victim *

Hospital/Facility Address (City, State, ZIP Code) *

Hospital/Facility Phone Number *

Admitting Physician: *

Please tell us about their insurance information:

Victim Health Insurance Provider *

Victim's Insurance Policy Number *

Is the victim covered by health insurance? *

Yes

What is their Employment Information?

Victim's Current Employment Status *

Employed

Self-Employed

Retired

Unemployed

Victim's Occupation

Victim's Employer Name:

Victim's Employer Address (City, State, ZIP Code)

Is the Accident Victim the Primary Income Earner? *

Yes

Is the Accident Victim currently Receiving Disability Benefits? *

Yes

Any legal proceedings and insurance claims?

Are there any ongoing legal proceedings related to the accident? *

Yes

Are there any insurance claims filed? *

Yes

Are there any relevant legal documents?

Select any relevant legal documents:

Power of Attorney

Will

Other (please specify)