Submit Case for Evaluation

Personal Injury Form

Using a form is helpful, but not required. You can always contact us or call us at 207-780-6700 or toll free at 800-425-6700.

Name

First Name

Last Name

Email Address

Subject

Phone

(###)

###

####

Please briefly describe the circumstances surrounding your injury

Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Age

Number of Dependants

Social Security Number

How were you referred?

Date of Injury

YYYY

Nature of Injury

Name of Opposing Party

Name of Opposing Party's Insurance Company

Who is your Insurance Company?

Employer

Did you lose time from work because of your injury?

Yes

How much did you earn, per week, before taxes, at the time of your injury?

Please list the names of the doctors who have treated you for your injury