Elevator Accident Case Intake Form

Elevator/Escalator Case Intake Form

Step1
Step2
Step3
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Step5

Section1

The accident happened on:

The location of the accident was:

The device I was injured by was an:

elevator escalator Other - Explain Below

Section2

The incident was reported to:

Police

Property owner

Other - Explain Below

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

Yes No

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

Yes No

Section3

The area of the accident had video cameras:

Yes No I don't know

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

Yes No

After the accident, I sought medical or hospital care:

Yes No

Section5

The injuries have caused me to:

seek medical attention

experience discomfort and pain

lose time from work

lose time from school

reduce my activities

Other - Explain Below

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.

Disclaimer

l understand and agree.

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Elevator and Escalator Accident Case Intake Form

Section1

The accident happened on:

The location of the accident was:

The device I was injured by was an:

Section2

The incident was reported to:

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:

Section5

The injuries have caused me to:

Additional Information:

Name:

My email address is:

My telephone number is:

Disclaimer