Name

Email Address

Phone Number

Were you or a loved one the victim of an accident involving a commercial truck?
Yes  No 

If the victim was a loved one, what is your relationship with that person?

When and where did the accident occur?

Were you or your loved one a passenger, driver, or pedestrian?
Yes  No 

How did the accident occur? Describe what happened.

What kind of truck was involved?

Do you know the name of the driver?
Yes  No 

His or her trucking company?
Yes  No 

His or her employer?
Yes  No 

Was a police report generated by the accident?
Yes  No 

Do you know if any traffic citations were issued?
Yes  No 

Do you know the names of any witnesses to the accident?
Yes  No 

What injuries were sustained as a result of the accident?

Did you seek and are you currently receiving medical treatment as a result of the accident?
Yes  No 

What is your prognosis?

Have you discussed this matter with your own insurance representative?
Yes  No 

Have you discussed this matter with any insurance representative or attorney representing other parties involved in the accident?
Yes  No 

How has this accident affected your overall quality of life and well-being?

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