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Name E-mail Date of Accident/Incident Contact Number Case Description Were you physically injured? Did you seek medical treatment immediately following this accident/incident? Were you transported to the hospital immediately following this accident/incident by ambulance? Have you sought any medical treatment pertaining to this accident/incident? If an accident, were you issued a ticket? Did your airbags deploy? Did you have active auto insurance and/or medical insurance at the time of this accident/incident? Who is your auto insurer? Your medical insurer? Type "n/a" if not applicable. What amount of auto insurance did you have at the time of this accident? In what state did this accident/incident occur? Did law enforcement come to the scene of this accident/incident? Was a police report filed concerning this accident/incident? Do you have the police report number pertaining to this accident/incident? Were there any witnesses to this accident/incident? If there are witnesses to this accident/incident, did they provide a statement to police? Was your vehicle damaged in this accident/incident? Please state the location of all damage to your vehicle (ie. right bumper, front driver side, etc.). Type "n/a" if not applicable. Did you obtain insurance information for the other party involved in the accident/incident? Was this a hit and run accident? Was the other party involved in this accident/incident injured? Was the other driver involved in this accident transported to the hospital via ambulance?
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By submitting the form on this website for case evaluation, or submitting an email via this website, I agree to the electronic transmission of the information provided herein. I further agree to be contacted via any contact method provided on the form for case evaluation, including text/sms messages for which I agree to be responsible for all applicable messaging and data rates. I agree that submission of the form for case evaluation is for potential case evaluation purposes, and neither guarantees case acceptance nor constitutes an agreement of legal representation. I further agree to assume all responsibility and liability for use of the www.attorneysolutions.org website, the accuracy or inaccuracy of information I provide via the www.attorneysolutions.org website-via email or otherwise, and hold www.attorney solutions.org, Attorney Solutions, its owners, heirs, employees, associates, representatives, affiliates, consultants, partners, investors, contractors, vendors, and the like blameless for any and all issues that may arise directly or indirectly from the use of www.attorney solutions.org and/or any and all Attorney Solutions services in perpetuity. I agree that Attorney Solutions representatives may share with third parties the information I provide and submit on this website via email and/or on the form for case evaluation to the extent necessary for thorough case evaluation as deemed by Attorney Solutions. I agree to hold www.attorneysolutions.org, Attorney Solutions, owners, heirs, employees, associates, representatives, affiliates, consultants, partners, investors, contractors, vendors, and the like blameless for any and all issues that may arise directly or indirectly from sharing information I provide and submit on this website via email and/or on the form for case evaluation with third parties in perpetuity. I agree to the use of my electronic signature, and I agree that my typed signature on the form for case evaluation or elsewhere on this website as applicable is equally as legally binding as my written signature.  Attorney Solutions reserves the right to update its Terms & Conditions at any time, with or without notice, and may at will restrict its website access to violators of its Terms & Conditions.  Attorney Solutions reserves the right to monitor its www.attorneysolutions.org website for suspicious activity, including but not limited to IP address capturing. Continued use of this website constitutes agreement with all current and updated Terms & Conditions.