Case Review
Case Review
Name
*
Name
First
First
Last
Last
Email
*
Phone
*
Address
*
Address
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Case type
*
Motor vehicle accident
Dangerous property (e.g. slip and fall, etc.)
Dangerous product
Dog bite or animal attack
Abuse (e,g. sexual, nursing home, etc.)
Construction accident
Defamation
Assault
Other
Case type
Date of Incident
*
Was the accident your fault?
*
Yes
No
Was a police or accident report made?
*
Yes
No
Unsure
Were you physically injured or in pain?
*
Yes
No
Identify all injured body regions
*
Brain
Head
Face
Neck
Spine
Vertebra
Chest (thorax)
Abdomen
Genitalia
Pelvic organ
Lower back and pelvis
Pelvic girdle
Buttock
Shoulder and upper arm
Forearm and elbow
Wrist, hand, and fingers
Other part of arm
Hip
Upper leg and thigh
Knee
Lower leg and ankle
Foot and toes
Ankle and foot
Unclassifiable by body region
Systemwide
Other
Other
Identify all injury types
*
Fracture
Dislocation
Sprain or strain
Internal organ injury
Open wound (abrasion, puncture, etc.)
Contusion or bruise
Superficial injury
Crushing
Amputation
Blood vessel
Burn
Corrosion (chemical burn)
Effect of foreign body entering orificae
Other effect of external causes
Injury to nerves
Injury to muscles or tendons
Poisoning
Toxic effects
Mental or emotional
Other
Other
Does anyone have auto insurance coverage?
*
Yes
No
Unsure
Were you taken from the incident by ambulance to ER?
*
Yes
No
Were you hospitalized other than visiting ER?
*
Yes
No
Did you receive medical treatment?
*
Yes
No
Did you miss work?
*
Yes
No
Did you have surgery?
*
Yes
No
Is an attorney helping you with your claim or has an attorney already rejected your claim?
Yes
No
Approximately how much are your medical expenses so far?
$1 – $5,000
$5,001 – $25,000
$25,001 – $100,000
$100.000+
Please describe the incident in question.
*
Captcha
Opt-in
*
By checking the box, you are expressly consenting to receive SMS communication from Manaster Law Firm PLLC. Message and data rates may apply. Message frequency varies. To opt-out, reply STOP. For help, reply HELP.
REGISTER
If you are human, leave this field blank.
Δ
