Personal Injury Questionnaire

For a free evaluation of your personal injury claim, please fill out the following form completely and submit it to us. We try to respond to all submissions by the following day. Please be aware that in submitting this form you are not retaining legal services from Moffett Law Firm, P.C.

Name

E-Mail Address:

Business Telephone Number:

Home Telephone Number:

Your Insurance Carrier:

Negligent Party's Insurance Carrier:

Date of Incident:

Place of Incident:

Investigated by:
State Patrol Sheriff Local Police Other Agency None

FACTS: In your own words, describe how the incident occurred.

What injuries resulted from the incident, who was injured, and how have the injuries progressed?:

What medical treatment has taken place?

Medical Expenses to Date:

Time Loss from Work to Date:

Property Damage:

Transportation Costs, Car Rental, etc:

Any Other Losses: