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.