Catastrophic Injuries Contact Form

If a catastrophic injury was caused by the negligent or intentional act of another, or by a dangerous or defective product, a personal injury claim by the victim will be an integral factor in his or her future quality of life, including the quality of the medical care and other support he or she will receive.

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Catastrophic Injuries Contact Form

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

How were you injured?

Who do you believe caused your injuries?

What are your injuries?

What body functioning has been impaired?

What activities are you precluded from doing because of your injuries?

What medical devices do you use to assist you?

Do any health care professionals provide you treatment in your home?

Does anyone assist you with your daily living needs?

Do you ever leave your home? How?

Has your health care insurance or medicaid/medicare paid your medical bills?

Have you altered your home in order to conduct your daily living activities? In what way(s)?

Have you received any assistance in performing your daily activities from family members? Have they been paid? Do they expect to be paid? How much?

Have your physicians told you how long you will be disabled?

Have you received any psychological care as a result of the accident?

Were you employed at the time of the accident?
Yes No

Did the accident happen while you were working?

Will you ever be able to return to the same type of employment?

Will you ever be able to return to restricted employment?

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