Dangerous Highways Contact Form

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

When and where did the accident occur?

Do you know the name/number of the highway where the accident took place?
Yes  No 

Can you identify any feature of the highway that contributed the accident?
Yes  No 

For example, were the sight lines sufficient or were there any hazards on the side of the roads that caused the accident or contributed to the severity of the injuries suffered?

What were the conditions? Light/Dark? Wet/Dry? Snow/Ice?

Where were you sitting in the vehicle?

Were you driving?
Yes  No 

Who owns the vehicle?

Is it insured?
Yes  No 

Describe how the accident happened.

Did the police come to the scene of the accident?
Yes  No 

Do you have a copy of the police report?
Yes  No 

How many vehicles were involved in the accident?

Did you or any other driver receive a citation related to the accident?
Yes  No 

What injuries did you suffer in the accident?

What medical treatments have you received and what treatment do you continue to receive?

What is your long-term prognosis?

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