Preferred Contact Method
Was the Other Party at Fault?
Type of Accident
Were You Injured?
Did You Receive Medical Treatment?
Was a Police Report Filed?
Do You Have Insurance?
Have You Missed Work Due to the Accident?
Do You Need Legal Assistance?
Referral Source Payment Method
Relationship to Accident Victim
Note: Payment will be processed only after liability is confirmed and the client is booked with the attorney.
