Hey there! What's your name?

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.

What's Your Address?

What's your relationship to the accident victim?

What are the accident victim's details?

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

Please tell us a little about the injuries.

Please tell us a little about the medical treatment.

Please tell us about their insurance information:

What is their Employment Information?

Any legal proceedings and insurance claims?

What about any assistance being sought?

Are there any relevant legal documents?

Are there any existing support network or community resources?

Are there any others involved in the accident?

Are there any specific Medical or Healthcare Needs? (e.g., Rehabilitation, Therapy, Specialists):

Any Other Relevant Information or Documentation?

Please ensure that you provide accurate and detailed information. We understand the sensitivity of the situation and assure you that all information provided will be treated with strict confidentiality. Our team will carefully review your request and contact you to discuss further steps and available support options. Thank you for reaching out to Gears in Heaven. We are here to assist you during this challenging time.

Please Read and Sign:

Legal Release: I, , hereby authorize Gears in Heaven and its representatives to discuss, obtain, and share information related to the accident and its aftermath with relevant parties, including medical professionals, legal advisors, insurance companies, and other necessary entities. This authorization extends to all information necessary to evaluate and provide appropriate support and assistance.

I understand that the information shared will be handled with strict confidentiality and used solely for the purpose of assisting in the evaluation and support process. I release Gears in Heaven and its representatives from any liability arising from the lawful use and disclosure of the information provided.