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Fifth Third Center 201 E. Kennedy Blvd. Suite 1475 Tampa, FL 33602
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Auto Accident Case Evaluation

Please answer as many of the following questions as you can.


Name:
Address:
City:
State:
Zip Code:
Email Address:
Phone Number:

 

***ACCIDENT INFORMATION***

 

When and where did the accident occur?
What were the road conditions? Wet/Dry? Light/Dark?
Did the police come to the scene of the accident?

 Yes No
If so, do you have a copy of the police report?

Yes No
What is the police Agency and Report Number?
Were any citations issued or arrests made?

 Yes No
Are you able to fax or email the report to us?

 Yes No
Where were you in the vehicle? Were you driving?
Who owns the vehicle you were in?
Who else was in the vehicle you were in?

 

***INSURANCE INFORMATION***

 

Is the vehicle you were in insured?

Yes No
If so, by which Ins. Co.?
Was the at-fault driver of the other vehicle insured?

Yes No
If so, by which Ins. Co.?
Was the at-fault driver the owner of the other vehicle?

Yes No
Have you been contacted by any insurance company?

Yes No
If so, by which Ins. Co.?
Have you provided a recorded statement to anyone?

Yes No
If so, by which Ins. Co.?

 

***INJURY INFORMATION***

 

How were you injured in the accident?
Were you taken to the hospital? Where? When?
What medical treatment have you since received?
Are you currently receiving medical treatment?

Yes No
Were any passengers injured?

Yes No
If so, what are the injured passenger’s names? Relation?
Was the other driver injured?

Yes No

 

***INJURY INFORMATION***

 

Please describe how the accident occurred:
Do you believe that alcohol was a factor in causing the accident?
Please list any other concerns:
 
DISCLAIMER: Sending an email through this form will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. Please do not send sensitive or confidential information via this email form. Email sent via the Internet might be intercepted and read by third parties.
Smith & Stallworth Information Center
Florida Personal Injury Florida Statewide Auto Accidents Tampa Motor Vehicle Accidents Tampa Wrongful Death
Click here to be instantly connected to our office Click here to send us an email directly
Send an Email (* indicates a required field)
Subject:
Your Name:
* Your Email Address:
Your Phone Number:
- - -
Your City:
Your Message:
 
DISCLAIMER: Sending an email through this form will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. Please do not send sensitive or confidential information via this email form. Email sent via the Internet might be intercepted and read by third parties.
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Address: Fifth Third Center   201 E. Kennedy Blvd, Suite 1475   Tampa, FL 33602   Toll Free: 877-888-JURY Phone: 813-223-7799