Please complete the following questionnaire regarding your Premises Liability case.

Premises Liability Questionnaire

Please complete this questionnaire regarding your premises liability case.

"*" indicates required fields

Personal Information

Date of Birth*
DO NOT file bankruptcy during pending litigation without first consulting your Attorney as it may impact your ability to recover settlement proceeds.
Please enter your full SSN or at minimum the last 4 digits.

Employment Information

Incident Information

Please provide a brief description of what happened.
Ex: store aisle, stairwell, parking lot
Drop files here or
Max. file size: 20 MB.
    If you are unable to upload the report, please text or email us a copy.
    Drop files here or
    Max. file size: 20 MB.

      Health Insurance

      Select Your Health Insurance Provider(s)*
      If you selected Private Insurance above, please include the name of your provider. If you have supplemental coverage or multiple providers, please specify which provider is associated with each Member ID Number. (Ex: Medicare 0012345, Humana 0098765)
      Drop files here or
      Max. file size: 20 MB.

        Medical Treatment & Injury Information

        This includes Emergency Room, Urgent Care, Chiropractor, Orthopedic Specialist, Physical Therapy, Etc.
        List of Medical Providers*
        Enter the name and location of each facility/provider that you have treated with. Use the “plus” button to add additional providers. It is VERY IMPORTANT that you list ALL medical providers you have treated with. (Ex: Emory Hospital Midtown, 550 Peachtree St NE, Atlanta, GA)
        Enter a brief description of your injuries. (Ex: Lower back pain, headaches, broken arm, Etc.)
        Please be truthful in your response to this question. Your answer is VERY important and necessary for us to give your case the best outcome. This information will not be shared with anyone outside our law firm.
        (Ex: Rear-ended in 2010, back injury, other driver’s insurance paid for my repairs.)
        Max. file size: 20 MB.
        This field is for validation purposes and should be left unchanged.