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Case Review
jpadmin
2018-09-24T21:57:21+00:00
Step
1
of
6
16%
How were you injured?
*
Auto Accident
Slip & Fall
Medical Malpractice
Semi Truck Accident
Motorcycle Accident
Dog Bite
Workers Comp
Did the accident happen within the last 4 years?
*
Yes
No
Was the injured party a minor at the time of injury?
*
Yes
No
Is the injured party over the age of 21 now?
*
Yes
No
Was there a citation issued?
*
I Got the Ticket
No Ticket Was Issued
I Got a Ticket But it Was for Something Like Not Having My Insurance Card
The Other Party Got the Ticket
What treatment have you received?
I've seen a Chiropractor
I had Surgery
I've received Physical Therapy
I've received Counselling
None, I'm injured but haven't received treatment
None, I wasn't physically injured
Treatment Not Listed
Which parties involved have insurance?
*
Only I Have Inurance
Only They Have Inurance
We Both Have Insurance
Neither of Use Has Insurance
I Don't Know
Name
*
First
Last
Email
*
Phone
*
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