"Most people are just looking for fair treatment."

Bob Chapman

Personal Information

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

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ACCIDENT DETAILS

Date accident occurred:
Where did accident occur?
City in which accident occurred:
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.

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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 !