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City

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Date of injury? - mm/dd/yyyy

Was the other person at fault?

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*Does either person have insurance?

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*Have you seen a doctor?

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Were you hospitalized?

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Are you in a hospital? If yes, which hospital:

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*Type of injury

Auto

Motorcycle

Pedestrian vs. Vehicle

Slip/trip and fall

Medical malpractice

Wrongful death

Other type of injury

Other type of case, not personal injury (divorce, etc.)

17011 Beach Boulevard
Suite 1270
Huntington Beach, CA 92647
(714) 541-9000
or
(800) 64-INJURY
800-644-6587
Toll-Free in Southern California

(909) 276-1100

2107 North Broadway
Suite 104
Santa Ana, CA 92706
(714) 543-8416
or
(888) Local Law
800-562-2552
Toll-Free in Southern California