Construction Accident Case Intake Form
Section1
The accident happened on
I was a(n):
Section2
Please describe how the accident happened:
The incident was reported to police:
section3
The incident was reported to my supervisor
After the accident, I sought medical or hospital care:
I injured my:
section4
The injuries have caused me to:
section5
Name
My email address is:
My telephone number is
I understand that the transmission of this information does not create an attorney client relationship but is, instead, a request for a free consultation with an attorney about the details of my potential case.