Georgia personal injury attorneys Head, Thomas, Webb & Willis
Georgia lawyers
helping victims
of negligence
Contact our firm Head, Thomas, Webb & Willis Attorneys in our firm Free case evaluation
 

Free case evaluation

You may use the form below to send your information to us electronically, or you may contact our office at (404) 250-1113. Complete the questions to the best of your ability--the more thorough you are, the better the attorney will be able to assist you.
LAST NAME
FIRST NAME
STREET ADDRESS
CITY
STATE
ZIP
PHONE (PLEASE INCLUDE AREA CODE!)
E-MAIL
YOUR DATE OF BIRTH
DATE OF ACCIDENT OR INJURY
LOCATION OF ACCIDENT OR INJURY
BRIEFLY DESCRIBE WHAT HAPPENED
WAS ANYONE ELSE INJURED?
DID THE POLICE MAKE A REPORT ABOUT THE ACCIDENT OR INJURY?

YES

NO
DID ANYONE WITNESS YOUR INJURY?
DID YOU OR ANYONE ELSE TAKE PHOTOGRAPHS, VIDEO, OR NOTES ABOUT THE SCENE OF YOUR ACCIDENT OR INJURY?

YES

NO
YOUR CAR INSURANCE INFORMATION

COMPANY

POLICY NUMBER

DOES YOUR CAR INSURANCE HAVE MEDPAY COVERAGE?

YES

NO
ARE THERE OTHER PEOPLE LIVING IN YOUR HOUSEHOLD ON YOUR CAR INSURANCE POLICY?

YES

NO
ARE THERE OTHER VEHICLES COVERED BY YOUR CAR INSURANCE POLICY

YES

NO
YOUR HEALTH INSURANCE INFORMATION
YOUR HOMEOWNERS INSURANCE INFORMATION
INSURANCE INFORMATION FOR OTHER PARTIES INVOLVED
DID YOU GO TO THE EMERGENCY ROOM OR SEEK MEDICAL ASSISTANCE FOR YOUR INJURIES
NAME OF HOSPITAL OR MEDICAL PROVIDER
ARE YOU CURRENTLY UNDER THE CARE OF A DOCTOR OR OTHER HEALTHCARE PROVIDER?

YES

NO
IF YOUR VEHICLE WAS INVOLVED, WAS IT "TOTALLED" OR OTHERWISE DAMAGED?
BRIEFLY DESCRIBE HOW THIS ACCIDENT OR INJURY HAS AFFECTED YOUR QUALITY OF LIFE

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