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Personal Injury Case Evaluation Form

Personal Injury Case Evaluation Form


Looking for more information on why you need a Personal Injury attorney in Fayetteville or Raeford, you can learn more about how our Personal Injury Attorneys can help you on our Personal Injury page. Ready to get started, fill out the form below:


*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Who was injured?

If "Other," please describe:

Injured person's name (if different from above):

Address:

City:

State:

Zip:

E-mail address:

Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

When did the injury occur?

Where did the injury occur?

Was this location the injured person's

If "Workplace," did the injury occur as a result of employment activities?
yesno

If "Other," was this a road accident?
yesno

If no, did the injury occur on another's property?
yesno

If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?
yesno

If yes, what are the witnesses names/contact information?

Were others involved or injured at the same time?
yesno

If yes, what are their names/contact information?

Was there a police report?
yesno

Did the injured person receive medical treatment?
yesno

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
yesno

Was the injured person killed as a result of the accident?
yesno

If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

Where did you hear about this website?

+ Request a Consultation

*Your Name

*Your Email

Please select either an Attorney or Practice.

Attorney

Practice

Questions/Comments

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

*Your Name

*Your Email

Please select either an Attorney or Practice.

Attorney

Practice

Questions/Comments

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

*Your Name

*Your Email

Please select either an Attorney or Practice.

Attorney

Practice

Questions/Comments

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

Practice Areas
Contact Information

Fayetteville Office:

Cumberland County
230 Green Street
Fayetteville NC 28301
P: (910) 323-4600
F: (910) 323-3403

Raeford Office:

Hoke County
127 W. Edinborough Ave.
P.O. Box 688
Raeford, NC 28376
P: (910) 875-3379
F: (910) 875-4030

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