Test Form

Step 1 of 10

What kind of accident was it?

• Car accident
• Motorcycle
• Truck / Trailer
• Slip & Fall
• Work Injury
• Other

When was your accident?

• Within 7 Days
• 1-4 weeks
• 1-3 months
• 3-6 months
• 6-12 months
• 1-2 years
• 2+ years

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In which State did your Accident occur?

— Select —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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Do you have insurance

• Yes
• No

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Did you receive medical treatment?

• Yes
• No

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How bad were your injuries?

• No injuries
• Minor injuries (no hospital)
• Soft tissue therapy
• Serious injuries (fractures, long-term)
• Fatality or wrongful death

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Who was at fault?

• Me
• Someone Else

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Did you file a police report?

• Yes
• No

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Are you currently working with an attorney?

• Yes
• No

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