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Step
1
of
6
16%
What was the date of the accident?
*
MM slash DD slash YYYY
Did you receive medical treatment?
*
Yes
No
Did You Go To a Hospital?
*
Yes
No
What kind of injuries were sustained?
*
Whiplash
Lost Limb
Brain Injury
Broken Bones
Spinal Cord Injury or Paralysis
Loss of Life
Unknown
Was a police report filed?
*
Yes
No
Was the accident your fault or were you issued a ticket for the accident?
*
Yes
No
Do you currently have an attorney representing you in this matter?
*
Yes
No
Have you received a settlement?
Yes
No
Name
*
First
Last
Phone
*
Email
*
What State Did The Accident Happen In?
*
AL
AK
AZ
AR
CA
CT
DE
FL
GA
HI
ID
IL
IA
KS
KY
LA
MD
MA
MI
MN
MS
MO
MT
NV
NH
NJ
NM
NY
NC
ND
OH
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
What Zip Code Did The Accident Happen In?
*
Please enter a number from
00501
to
99950
.
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