First Name (required)

Last Name (required)

Your Email (required)

Your Address

Select Your State:
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Your City

Your Zip Code

Are you currently represented by a lawyer?
YesNo

Are you filling out this Application for yourself or someone else?
MyselfSomeone Else

Choose your appropriate case
-- Select One --Bicycle AccidentCar AccidentCommercial Vehicle AccidentFall AccidentInjury at WorkMotorcycle AccidentPedestrian AccidentProduct LiabilitySexual Assault or RapeShooting or Violent CrimeUber or Lyft AccidentOther

[group Bicycle-Accident]

When did the collision happen?

Did the police come to the scene of the collision?
YesNo

What City or county did the collision happen?

Select one of the following
Riding under the influence of drugs or alcoholTexting while ridingHit and RunOther

Have you seen doctors, receive treatment or therapy?
YesNo

Have you had surgery?
YesNo

Is future surgery likely?
YesNo

Did you lose consciousness?
YesNo

Was anyone else hurt?
YesNo

Any other additional information?

[/group]

[group Car-Accident]

When did the collision happen?

Were you a driver or passenger?
DriverPassenger

Did the police come to the scene?
YesNo

What City or county did the collision happen?

Select one of the following
Riding under the influence of drugs or alcoholTexting while ridingHit and RunOther

Have you seen doctors, receive treatment or therapy?
YesNo

Have you had surgery?
YesNo

Is future surgery likely?
YesNo

Did you lose consciousness?
YesNo

Was anyone else hurt?
YesNo

Any other additional information?

[/group]

[group Commercial-Vehicle-Accident]

When did the collision happen?

Were you a driver or passenger?
DriverPassenger

Did the police come to the scene?
YesNo

What City or county did the collision happen?

Select one of the following
Riding under the influence of drugs or alcoholTexting while ridingHit and RunOther

Have you seen doctors, receive treatment or therapy?
YesNo

Have you had surgery?
YesNo

Is future surgery likely?
YesNo

Did you lose consciousness?
YesNo

Was anyone else hurt?
YesNo

Any other additional information?

[/group]

[group Fall-Accident]

When did the fall happen?

Where did the fall happen?
Commercial AreaApartment or HotelSidewalkPrivate HomeOther

What part(s) of the body were injured? (neck, back, hips, knees, ankle, etc.)

What city or county did it happen?

Have you seen doctors, receive treatment or therapy?
YesNo

Have you had surgery?
YesNo

Is future surgery likely?
YesNo

Did you lose consciousness?
YesNo

Any other additional information?

[/group]

[group injury-at-work]

When did the Injury happen?

What company or person were you working for?

What was your job title?

Where you working with machinery when you got hurt?
YesNo

Approximately how many employees did your employer have?

What city or county were you hurt in?

What were you doing at the moment you got hurt?

Have you seen doctors, receive treatment or therapy?
YesNo

Have you had surgery?
YesNo

Is future surgery likely?
YesNo

Did you lose consciousness?
YesNo

Any other additional information?

[/group]

[group motorcycle-accident]

When did the collision happen?

Did the police come to the scene of the collision?
YesNo

What City or county did the collision happen?

Select one of the following
Riding under the influence of drugs or alcoholTexting while ridingHit and RunOther

Have you seen doctors, receive treatment or therapy?
YesNo

Have you had surgery?
YesNo

Is future surgery likely?
YesNo

Did you lose consciousness?
YesNo

Was anyone else hurt?
YesNo

Any other additional information?

[/group]

[group pedestrian-accident]

When did the collision happen?

Where you were when the collision happened?

Did the police come to the scene?
YesNo

Was rideshare services involved?
YesNo

What city or county did the collision happen in?

Select one of the following
Riding under the influence of drugs or alcoholTexting while ridingHit and RunOther

Have you seen doctors, receive treatment or therapy?
YesNo

Have you had surgery?
YesNo

Is future surgery likely?
YesNo

Did you lose consciousness?
YesNo

Was anyone else hurt?
YesNo

Tell us what part of your body were injured. (neck, shoulder, back, legs, etc.)

Any other additional information?

[/group]

[group product-liability-accident]

When did the failure happen?

What kind of product failed?

When did you purchase the product?

What were you doing when the product failed?

What city or county did the product fail in?

Have you seen doctors, receive treatment or therapy?
YesNo

Have you had surgery?
YesNo

Is future surgery likely?
YesNo

Did you lose consciousness?
YesNo

Was anyone else hurt?
YesNo

Tell us what part of your body were injured. (neck, shoulder, back, legs, etc.)

Any other additional information?

[/group]

[group sexual-assault]

When did the assault happen?

Who was the attacker?

What was the attackers relationship to you, if any?

Where did it happen?

How old were you when it happened?

What city or county did it happen in?

Any other additional information?

[/group]

[group shooting-violent-crime]

When did the shooting or violent crime happen?

What happened? (shooting, stabbing, hitting or beating, etc.)

Who was the attacker, if you know?

Where did it happen??

What was the attackers relationship to you, if any?

How did it happen?

Where the police notified?

What city or county did the attack happen?

Have you seen doctors, receive treatment or therapy?
YesNo

Have you had surgery?
YesNo

Is future surgery likely?
YesNo

Did you lose consciousness?
YesNo

Was anyone else hurt?
YesNo

Tell us what part of your body were injured. (neck, shoulder, back, legs, etc.)

Any other additional information?

[/group]

[group uber-lyft-accident]

When did the collision happen?

Where you a driver or passenger?
DriverPassenger

Did the police come to the scene of the collision?
YesNo

Select one of the following
Riding under the influence of drugs or alcoholTexting while ridingHit and RunOther

Did the airbags in your vehicle go off?
YesNo

What city or county did the collision happen?

Have you seen doctors, receive treatment or therapy?
YesNo

Have you had surgery?
YesNo

Is future surgery likely?
YesNo

Did you lose consciousness?
YesNo

Was anyone else hurt?
YesNo

Tell us what part of your body were injured. (neck, shoulder, back, legs, etc.)

Any other additional information?

[/group]

[group others]

When did it happen?

Who did something wrong, illegal, or dangerous?

What city or county did it happen?

Tell us what happened?

Was anyone else hurt?
YesNo

Were you or someone you care about injured?
YesNo

Did it cause monetary or financial loss to someone?
YesNo

Any other additional information?

[/group]