Disc Injury: Auto Accident Lawyers Claims Form

Herniated Disc Injury: Car Accident Lawyers and Attorneys

We are associated with experienced auto accident attorneys who have experience handling all types of auto accident claims including disc injury claims. The attorneys handle the case for no money up front, and then deduct their fee from the final settlement.

Contact us for a free claims evaluation.
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Title:
First Name:
M. I.
Last Name:
Address:
City:
State:
Zip Code:
Phone Number (day):
Phone Number (eve):
Email Address
If this inquiry is not for yourself, please tell us the name of the person?:
Title:
First Name:
MI
Last Name:
What is the Injured's relationship to you?:
Injured's Date of Birth? (ie . mm/dd/19yy)
Have you or they been been in an auto accident?:	Yes No
Date of accident? (ie . mm/dd/19yy)
What city and state did the accident occur in?
What were your Injuries?
What type of medical treatment was received?
Who was responsible for the accident?
Was the person(s) injured wearing a seat belt?
Did the Police respond to the accident?	Yes No
Did anyone recieve a ticket?	Yes No
Did the other driver have insurance?	Yes No
Do you have insurance?	Yes No
Do your currently have an attorney?	Yes No
Describe your injuries and Accident.
I understand that submitting this form does not create an attorney client relationship: Agree

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