ONLINE EVALUATION FORM


Everything is Confidential. There is absolutely no obligation.




Please complete and submit the Online Evaluation Form below.  This information will allow us to give you a more complete and accurate FREE evaluation of your Personal Injury Claim!  If you do not know the answer to a question or do not understand a question that is okay.  We can talk more on the phone after we receive your submitted Online Evaluation Form.   Once your Online Evaluation Form is submitted we will contact you right away and schedule a FREE consultation. 

Name
Phone Number(s)
Email Address
Address
Date of Accident
Date of Birth
Description of the Accident
Liable Person's Name, Address and Phone Number
Witness(es) Name, Address and Phone Number
Description of Your Injuries
Police/Other Investigation Report Number/Information
Health Care Providers Name, Address, Phone Number and Reason for Visit (e.g. 'left shoulder pain')
Prior Medical History
Your Auto Insurance, Adjustor's Name, Address, Phone and Claim Number
Indicate if you have Personal Injury Protection (PIP) and/or Under-Insured Motorist (UIM) and coverage amount
Your Health Insurance's Name, Address, Phone and Claim/Policy Number
Liable Party's Insurance, Adjustor's Name, Address, Phone and Claim Number
Your Employer's Name, Address and Phone Number
Your Preferred Method of Contact
Submit

No Attorney-Client Relationship is Created by Use of this Website or Any Associated Forms

The use of this website or the information contained herein, the submission of the Online Evaluation Form or any other information provided by you for our review and evaluation of your claim  does not create an attorney-client relationship.  There is no attorney-client relationship unless and until the attorney and client both sign a written agreement as required by the Rules of Professional Conduct of the State of Washington.