Online Interview | Mike Nelson PLC Gaylord Michigan (MI) Attorney at Law

YOU ARE HERE » Online Interview

Online Interview

This interview form is to let us know a little about your circumstance before we meet.

* Required information.

Date: *
Initials *
Type of Case:
Name: *
Phone: *
Address: *
Cell#:
Social Security Number: *
Date of Birth: *
Employer:
Date of Accident:
Location of Accident:
Are you off work or disabled?
If yes why?
Description of Accident
Description of Injury/Disability:
Were you hospitalized at the time of the accident?
If yes, were you admitted and treated or released?
Presently treating?
If yes, by whom?
For what condition?
Scarring? If yes describe.
Present disability and/or physical limitations:
Has doctor indicated permanency?
If yes, of what injury and why?
Are benefits voluntarily paid? If yes, what amount?
Negligence and/or 3rd party information: (Defendant-Insurance Company) Comments
Have you consulted with another attorney on this matter?
How did you hear about us?

Hover over the left image and enter the security code into the right textfield.

News2