Welcome! Please take a few moments to give us information about yourself, the incident and your injuries. Step 1 of 3 - Client Information 0% Referred By: (list name, Internet, etc.) Date of Accident(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920First Name(Required) Last Name(Required) Best Phone Number(Required)Alternate Phone NumberEmail(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How long have you lived in Florida?(Required) Marital Status(Required)SingleMarriedWidowedSpouses Name Please mark your HIGHEST level of Education(Required)Some High SchoolHigh School Graduate or GEDSome College or Associates DegreeBachelors DegreeGraduate or Professional Degree (MBA, Phd., J.D., M.D., Etc.)Do you have health insurance? Yes No Please select all that may apply:(Required) Private health insurance (employer provided or independently obtained) Employer provided ERISA Plan Medicare Medicaid Tricare V.A. Other Social Security NumberDo you have Children?(Required) Yes No How Many?(Required) Ages(Required) Are you Currently Employed?(Required) Yes No Where are you Employed?(Required) How long have you been employed with your employer?(Required) Please briefly explain your job title and duties(Required) Have you Missed any work as a result of your injuries?(Required) Yes No How many days?(Required) What is your rate of pay?(Required) Please select which best describes your incident:(Required)MVA (Motor Vehicle Accident)Slip and Fall or other premises liabilityNursing Home NegligenceMedical MalpracticeDog BiteBurnsMedical MalpracticeOtherLocation of the Incident(Required) Street Nearest Intersection if motor vehicle accident City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State County Please describe in your own words how the incident happened:(Required)Were you wearing a seatbelt?(Required) Yes No Not Applicable Were you working at the time of the incident?(Required) Yes No Not Applicable Did the airbags in the vehicle you were in deploy?(Required) Yes No Not Applicable Did Law Enforcement respond to the scene?(Required) Yes No Not Applicable What Agency did the investigation? Were you given a driver exchange of information sheet?(Required) Yes No Not Applicable Was an Incident Report made?(Required) Yes No Not Applicable Do you have a copy?(Required) Yes No Not Applicable To the best of your knowledge, were there any citations given to any parties to the incident?(Required) Yes No I don’t know Please list the name of the at fault Driver(Required) Please List your Auto Insurance Carrier(Required) Please list the at Fault vehicles Auto Insurance Carrier Please Describe the Symptoms and Injuries you're feeling so far:(Required)Have you had medical treatment since the incident?(Required) Yes No List all medical providers you have seen since the accident:(Required)YearMake Model Owner of the vehicle you were in: Approximate Amount of Property Damage to the vehicle you were in Where is the vehicle located now Which Insurance Company is handling the property damage to the vehicle Consent I agree to the privacy policy.CommentsThis field is for validation purposes and should be left unchanged.
