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Elevator/Escalator Case Intake Form

  • Step1
  • Step2
  • Step3
  • Step4
  • Step5

Section1

The accident happened on:

The location of the accident was:

The device I was injured by was an:

Please Explain:

The accident happened because the escalator:

This accident happened because the elevator:

Please Explain:

Please Explain:

Section2

The incident was reported to:

Please Explain:

I have a copy of the incident report, if one was prepared:

I have pictures of the device that caused me to be injured:

Section3

The area of the accident had video cameras:

I have, or can get the name of, a witness to the accident:

After the accident, I sought medical or hospital care:

Section4

I injured my:

Please Explain:

Section5

The injuries have caused me to:

Please Explain:

Additional Information:

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.

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