BCW&S

Personal Information

Your Name
Address
City
State	ZIP
Home Phone
Work Phone
Fax (if available)
E-mail
Best Times To Contact You

ACCIDENT DETAILS

Date accident occurred:

Where did accident occur?

City in which accident occurred:

Driver of vehicle in which you were traveling when injured:

Who was at fault?

Is there a conflict about who was at fault? Yes No

Briefly explain conflict, if one exists, about who was at fault.

Does the owner of the "at-fault" vehicle have insurance? Yes No

Insurance company for "at-fault" vehicle:

Do you have insurance coverage? Yes No

What is the name of your insurance company?

If your personal injury does not arise from a motor vehicle accident, please briefly describe how you were injured.

Briefly describe any property damage that occurred.

Briefly describe personal injuries.

What is the name of the treating doctor?

Did you give a recorded statement of the accident? Yes No

If no, we recommend that you do not give a recorded statement to the adverse insurance company until you have sought legal advice from a competent attorney.

WHAT TO BRING TO YOUR FIRST APPOINTMENT

    Insurance coverage "face sheet" (gives coverage in the various categories)
    Police Report
    Medical Bills
    Medical Records
    Information on other party
    Correspondence from either insurance company

    Basically anything you might have regarding this accident.

We do not represent you until a retainer agreement is signed.
We will review your report and contact you as soon as possible.

Thank you !