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Case Form

In order to determine whether you have a case, please complete the following CASE FORM. We will treat this information as confidential and will respond within 24 hours of receipt.

Fields marked with * are mandatory

Name:

Address:

City:

State:

Zip Code:

Email:

Phone:

Please Detail your Question here:

Type of Injury:

Date of Injury:

Description of Events That
Led to Injury:

Number of People Involved
in Accident:

Was an Emergency Medical
Team Deployed?: YesNo

If yes, give name
of EMT responding:

Were the Police Contacted/Deployed?: YesNo

If yes, give name
of Agency responding:

Officer on scene (Name/Badge
Number):

Was a Ticket Issued?: YesNo

If yes, who received
the ticket?:

Was an Accident Report
Filed?: YesNo

If yes, what is
the case number?
#:

Do You Have a
Copy of the
Report?: YesNo

Were there Environmental/Climate Factors
Impacting this Incident?: YesNo

If yes, explain:

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