BODILY INJURY
CLAIM VALUE

Name *

First

Last

Date of Accident *

Your Phone Number *

Your Email Address *

Were you performing any duties for your employer when this accident happened? *

What are your injuries? *

Have you received treatment for your injuries? *

If you have received treatment, who treated you and when?

What are your total medical bills?

Are you done with treatment?

Did you miss time out of work because of this accident? *

How much time did you miss?

Do you have any PERMANENT injuries because of this accident? *

What are the permanent injuries?

How much damage was done to your vehicle? *

Was anyone else with you in the vehicle when this accident happened? *

Were they also injured?

Was the driver of the OTHER vehicle given a ticket by the police? *

Do you know what the OTHER driver's ticket was for?

Was the OTHER driver given a ticket for DWI?

What was the OTHER driver's ticket for?

Did you give the AT FAULT DRIVER's insurance company a statement? *

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1201 North Tryon Street
Charlotte, NC 28206

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