Type of Case: Select Type of Case Commercial Dispute Boating Accident Longshoreman's Claim Seaman's Claim Maritime Lien Other (please describe below)
If "Other", please describe:
Upload File
If you have a word document (.doc) or Adobe Acrobat file (.pdf) of the incident, you can upload that file instead of filling out the form fields below. Be sure to fill out the fields marked with the asterisk (*) as those are required.
Date of incident:
City, State where incident took place:
Describe the incident as fully as possible:
Who do you believe was at fault, and what do you believe they did wrong?
Do you have any other information which you believe would help us help you?
Describe your injuries, losses or damages. If you know, state whether you have a permanent injury. If you know, what are your total medical bills to date?
Have you lost any earnings? Are you still off work? What kind of work do you do, and how much do you earn per week or per month?
Have you suffered any other losses because of this incident and, if so, please describe your losses:
Were you married when the incident occurred and, if so, has your spouse suffered any loss or damage because of the incident?
Have you negotiated with any insurance company, or any other person, in connection with this claim? If yes, please answer the following questions.
What was the lowest settlement amount that you asked for?
What was the highest amount that you have been offered to settle?
Have the medical or funeral bills or lost wages been paid for by: Workers Compensation Medicare, medicaid, or some other government program Employer's health plan Private insurance Other