Online Case Questionnaire

    Your Personal Information
    (Fields with * are required)

    *First Name:

    *Last Name:

    *Phone:

    *Your Email:

    Alternate Phone:

    Mailing Address:

    City:

    State:

    ZIP:

    Driver's License:

    Best time to contact you:

    Information About The Incident

    Date: (mm/dd/yyyy)

    Time:

    County:

    Street:

    Describe how the Incident occured in detail:

    Was there a Police Report? YesNo

    What Agency?

    Did you receive medical care at the scene? If so, describe the nature of the treatment:

    Were you transported by Ambulance? YesNo

    To where?

    Describe each of your injuries:

    Name all the doctors, hospitals or treatment facilities who have treated you for these injuries:

    How much have you incurred in medical bills to date?

    Names and addresses of any witnesses to the incident:

    Did you miss time from work? YesNo

    How much time?

    Employer's Name:

    Employer's Address:

    City:

    State:

    ZIP:

    Employer's Phone:

    Supervisor's Name:

    How long have you worked there?

    Rate of pay?

    Describe any other damages resulting from the incident:

    Information About the Adverse Party

    Adverse Party Name:

    Adverse Party Address:

    City:

    State:

    ZIP:

    Adverse Party Phone:

    Adverse Party's Insurance Co.:

    Insurance Co. Address:

    City:

    State:

    ZIP:

    Insurance Co. Phone:

    Policy No.:

    Claim No.:

    Name of Insurance Contact Person (if known):

    Insured's Name (if different from Adverse Party):

    City:

    State:

    ZIP:

    Insured's Phone:

    Disclaimer: The transmission of this information does not create an attorney-client relationship. An attorney-client relationship will exist only if a written fee agreement is entered into between Altemus & Wagner and the individual asserting a claim. Nothing in this transmission shall give rise to any legal duty or obligation on the part of Altemus & Wagner.

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