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Case Evaluator

Case Evaluator


Name:
E-mail Address:
Phone Number:
Age:
Sex : Male Female
Type of loss: Auto
Motorcycle
Slip and fall
Medical and negligence
Pedestrian or bicycle
Other
Briefly describe accident:
Was the other party cited with violation of traffic statute? Yes No
Check all that apply:

I injured my:
Neck
Back
Shoulder
Knees
Headaches
Lacerations which required stitches or sutures
Fractured bones, if so describe

Check all that apply: I was transported by ambulance
I sought treatment in the Emergency Room
I am presently under the care of a doctor or chiropractor
I need medical treatment
I had or it is recommended I have surgery, if so describe
My Medical expenses are approximately $
I have missed days/weeks of work and my rate of pay is