Additional Information: Please upload supporting case documents...

TortX Intake Form

Caller's Information

What is your full name? *

What is your phone number? *

Do you have an alternate phone number? If yes, what is it?

What is your email address? *

What is the best time to contact you? *

What is the best method to contact you? *

What is your Gender? *

What is your social security number? (Either the last 4 or just enter in 0000) *

What is your current Street Number and Street Name? *

What is your city? *

What state do you live in? (MUST use 2 digit abbreviation. Example for Florida enter in FL, For Colorado enter in CO) *

What is your zip code? (Enter in 5 digits) *

What is your Date of Birth? (MM/DD/YYYY) *

What is your relationship to the claimant. (*If filing for self, please pick self) *

If you are not filing for yourself, what is your relationship to the injured party?

Emergency contact fields

What is the name of someone we can contact in an emergency?

What is the phone number of your emergency contact person?

What is the email of your emergency contact person?

What is your relationship to your emergency contact person?

Accident Information

What type of accident occurred? *

Have you ever been represented by an attorney for this claim? *

Are you currently represented by an attorney for this claim? *

Have you accepted a settlement for this claim? *

What was the date of the accident? *

What city did the accident happen in? *

What state did the accident happen in? *

Were you at fault for the accident? *

Was another other party at fault for the accident? *

Were you cited (given a ticket) for the accident? *

Was another party cited (given a ticket) for the accident? If they do not know, put no. *

Is the other party covered by insurance? *

What type of injury did you/the injured party sustain? *

If other, please list out the type of injury.

What type of treatment did you/injured party receive? *

If other, please list out the type of treatment.

What date did treatment start? (When did they go to the hospital or when did they see a doctor first) *

What is the name of the facility where you were seen for treatment? *

What is the address of the above facility? (You might need to google to get the full address) *

Was a commercial or corporate party involved? (Example: Amazon driver hit them. This would be marked as Yes) *

If it was an MVA, what type of accident was it?

Do you have documentation related to the accident? *

Please write a short description of what happened. *

Have you filed an insurance claim yet? *

Anything else important to add, please write out here.

Injured Party Name

What is the injured parties full name? If filing for themselves, please fill in their full name like you did above. *

Injured Party Information Only fill out IF the caller is NOT filing for themselves

Injured party phone number.

Injured party alternate phone number.

Injured party email address.

Best time to contact injured party.

Best method to contact injured party.

Injured party gender.

Injured party SSN.

Injured party street address.

Injured party city.

Injured party state.

Injured party zip code.

Injured party date of birth.

Injured party date of death.

Injured party cause of death.