Auto Collision Case Evaluation

NOTE: An asterisk (*) indicates REQUIRED information. The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

  

Contact Information
*First Name:   
*Last Name:   
*Email Address:   
*Phone:   
Alt. Phone:   
Address:   
City:   
State/Province:   
Zip:   
 

Accident Information
Date of Accident   
Location of Accident   
Was the accident investigated by law enforcement?    YesNo
What law enforcement agency performed the investigation?   
Were you the driver or passenger?   
What type of car were you driving or riding in?   
What is the estimated amount of damage to the vehicle you occupied?   
List all witnesses to the accident.   
What is the name of the person who caused the accident?   
Describe how the accident happened?   
 

Injury Information
Nature of your injury   
Did you leave the accident in an ambulance?    YesNo
Did you go to the hospital?    YesNo
What Dr. have you seen regarding your injuries?   
Who referred you to Johnson, Clifton, Larson & Schaller?   
 

Insurance Information
Who is the insurance provider of the vehicle you occupied?   
Who is the insurance provider of the vehicle that caused the accident?   
Have you contacted the insurance company of the person who caused the accident?   
Do you have a claim number?    YesNo
If yes what is the claim number?   
Do you know the name of the adjuster?   
Has a recorded statement been done?    YesNo
  
 

Closest Living Relative
Name:   
Address:   
Phone:   
  
 

Comment
* Please add any additional information that you would like us to consider.

The Oregon personal injury trial attorneys at Johnson, Clifton, Larson & Schaller, P.C. represent plaintiffs in personal injury and wrongful death cases involving medical malpractice, motor vehicle accidents, truck accidents, disabled persons' tort claims, nursing home negligence or elder abuse, construction and industrial accidents, birth injury cases, and product liability and defective medical device cases. Our Eugene medical malpractice lawyers serve clients throughout central Oregon, southern Oregon, and the Willamette Valley, including Corvallis, Salem, Medford, Roseburg, Klamath Falls, Bend, Redmond, Ashland, Creswell, Central Point, Grants Pass, Brownsville, Myrtle Creek, Springfield, and Albany, OR.

Lane County ◦ Marion County ◦ Benton County ◦ Douglas County
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