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Contact Us
Tell Us About Your Accident
Derek Iorg
2024-04-25T19:55:27+00:00
Accident Info
Step
1
of
8
12%
What Type of Accident Were You Involved in?
How were you hurt?
(Required)
Car Accident
Truck Accident
Bicycle or Pedestrian Accident
Motorcycle Accident
Other Motor Vehicle Accident or Injury
How long ago was the accident?*
How long ago was the accident?
(Required)
In the last 14 days
Within 1-3 months
Within 3-6 months
Within 6-12 months
More than a year ago
More than 2 years ago
Was the accident your fault?*
Was the accident your fault?
(Required)
No, it was not my fault
Yes, it was my fault
Did the police arrive?*
Did the police arrive?
(Required)
Yes
No
I don't know
How were you injured?*
How were you injured?
(Required)
Fatality or Wrongful Death
Severe Injury: Dismemberment, Broken Bones, Fractures, Body Organ Injury, Concussion
Moderate Injury: Soft Tissue Neck and Back Pain or Whiplash
No Physical Injuries
Are you currently represented by an attorney for this accident?*
Are you currently represented by an attorney for this accident?
(Required)
No, I do not have an attorney
I have an attorney but I'm looking for someone else to represent my case
Yes I have an attorney
I have already settled my case
Please describe your accident and injuries*
Please Describe Your Accident and Injuries
(Required)
First and Last Name?*
What is your first and last name?
(Required)
First
Last
Best email to reach you?*
Best email to reach you?
(Required)
Your cell phone number?*
Your cell phone number?
(Required)
A team member will contact you shortly to discuss your maximum compensation
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Tell Us About Your Accident