Instant Injury Help
If you have been injured by someone else’s negligence act now without delay. Contact us by filling out the form below and we will work to get you the money to make you whole.

Rather speak to an attorney right now on the phone? Call 949-261-0553

AUTO ACCIDENTS
Automobile/SUV/Pick-Up, Drunk Driver, Passengers
MOTORCYCLE ACCIDENTS
Motorcycle, Moped, Scooter
TRUCK ACCIDENTS
Tractor/Trailer, Big Rig, Semi-Truck, Pick-Up Truck
UNINSURED MOTORISTS
Uninsured, Underinsured, No License, Non-Resident
PEDESTRIAN ACCIDENTS
Crosswalk, Jaywalking, Runners, Walkers
BICYCLE ACCIDENTS
Road Bikes, Mountain Bikes, Scooters, Skateboards
TRAIN/BUS/BOAT ACCIDENTS
Amtrak, Metrolink, Freight, Buses, All Watercraft
DOG BITES
Bites, Attacks, All Animals
WRONGFUL DEATH
Death, Funeral Expenses, Heirs Rights

Injury Evaluation

Life for an injury victim often times becomes much more difficult after the injury. Not only does the victim suffer physically (and possibly mentally) as a result of an injury, but now the victim or a representative must deal with doctors, insurance companies and possibly attorneys. Each will require the victim or a representative to provide them with documentation. If you are the person providing the documentation, filling in the form below will prepare you for most of the questions these individuals need answered.

Personal Injury Claim - Client Guideline

Name

Date of Birth (day/month/year) / /

Address line 1

Address line 2

City

State

Zip Code

Home Phone

Work Phone

Mobile Phone

E-mail Address

Best method to reach you

Best times to reach you

Married Single Divorced

Number of children

If married, spouse's name

On what date did your injury occur? (month/day/year) / /

Where did your injury occur?

City State

Describe how your injury occured

Who do you believe caused or is responsible for your injury, and why?

Describe your injuries

List all doctors and health care providers who have treated your injuries. (Include their names, addresses, and telephone numbers)

Total medical expenses incurred to date for your injuries

Total medical expenses you expect to incur in the future

List the names, addresses, and telephone numbers of all insurance companies that may be involved (include as applicable, any automobile insurer, health insurer, homeowner's insurer, etc.).

Have you lost income due to your injuries?

Yes No

If yes, amount of lost income $

Income before injury $ per

Income after injury $ per

Employer

Position

Employer's Address

Employer's telephone number

Are you currently working?

Yes No

Expect to return to work on (month/day/year) / /

Will not return to work

Are you in pain? If so, describe.

Describe any other ways in which your life has changed as a result of your injuries. (For example, you are no longer able to engage in athletic activities, your appearance has changed, you cannot care for your children, etc.)

If married, has your spouse experienced any losses as a result of your injury? If so, describe.

List the names, addresses, and phone numbers of any possible witnesses in your case.

Have you previously consulted an attorney regarding your case?

Yes No

If yes, provide the attorney's name(s), the firm name(s), the address(es), and the telephone number(s).

Is your relationship with the attorney ongoing?

Yes No

Has an attorney declined to represent you in this matter?

Yes No

If yes, why?

Questions you have about your case