How were you injured?

Automobile Accident
Motorcycle or Bicycle Accident
Slip and Fall
Dog Bites
Other

What are the nature of your injuries?

Do you have any pre-existing injuries to the injured part of your body?

Yes
No

Were you treated for your injuries?

Yes
No

If so, when and where were you treated:

Were there any witnesses?

Yes
No

Have you filed a police report?

Yes
No

Do you have insurance that covers you for this type of incident?

Yes
No
Not Sure

Do other involved parties have insurance that covers this type of incident?

Yes
No
Not sure