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Personal Injury Intake Form

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Details Name Please enter your name.

Street Address Please enter your street address.

City Please enter the name of your city.

State Please choose your state of residence. ZIP Code Please enter a valid ZIP code. You may use 0-9, spaces and the ( ) - + characters.

E-mail Address

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Home Phone Number Please enter a valid home phone number. You may use 0-9, spaces and the ( ) - + characters.

Business Phone Number Please enter a valid business phone number. You may use 0-9, spaces and the ( ) - + characters.

Mobile Phone Number Please enter a valid mobile phone number. You may use 0-9, spaces and the ( ) - + characters.

Fax Number Please enter a valid fax number. You may use 0-9, spaces and the ( ) - + characters.

Who was injured? Who was injured? If you selected "other", please describe your relationship to the injured person. Please describe your relationship to the "other" injured person.

Injured person's name, if different from above. Please enter the injured person's name, if different from above.

Injured person's address Please enter the injured person's street address.

Injured person's city of residence Please enter the name of the city in which the injured person lives.

Injured person's state of residence Please choose the injured person's state of residence. Injured person's ZIP code Please enter the injured person's ZIP code.

Injured person's e-mail address Please enter the injured person's e-mail address.

Injured person's home phone number Please enter the injured person's home phone number.

Injured person's business phone number Please enter the injured person's business phone number.

Injured person's mobile phone number Please enter the injured person's mobile phone number.

Injured person's fax number Please enter the injured person's fax number.

When did the injury take place? Please enter the date the injury took place.

Where did the injury take place? Please enter where the injury took place.

Was this location the injured person's workplace, school, home or another location? Please indicate if the site of injury was the injured person's workplace, school, home or other.

Please indicate if the injury occurred as a result of employment activities. This injury occurred as a result of employment activities.

This injury did not occur as a result of employment activities.

Please indicate if the incident was a motor vehicle accident. This incident was a motor vehicle accident.

This incident was not a motor vehicle accident.

Please indicate if the injury occurred on someone else's property. The injury occurred on someone else's property.

The injury did not occur on someone else's property.

If the injury occurred on someone else's property, who owns it? Please name the owner of the property where the injury took place.

Describe how the injury happened. Please describe how the injury happened.

Describe the circumstances surrounding the injury. Weather and lighting are two examples. Please describe the circumstances surrounding the injury.

Please indicate if there were any witnesses. There were witnesses.

There were no witnesses.

Provide the names and contact information of the witnesses. Please provide the names and contact information of the witnesses.

Are any other people involved? Other people are involved.

No other people are involved.

Provide the names and contact information of the other people involved or injured. Please provide the names and contact information of the other people involved or injured.

Please indicate if a police report was filed. A police report was filed.

A police report was not filed.

Please indicate if the injured person received medical treatment. The injured person received medical treatment.

The injured person did not receive medical treatment.

If medical treatment was provided, provide the dates, locations, providers and details of the treatment. Please provide the dates, locations, providers and details of the medical treatment.

Is the injured person is still receiving treatment? The injured person is still receiving treatment.

The injured person is no longer receiving treatment.

Please indicate if the injured person died as a result of the incident. The injured person died as a result of the incident.

The injured person survived the incident.

If the injured person died, provide the date of death. Please provide the date the injured person died.

How has the injured person's life and the lives of his or her family members changed as a result of the injury? Please describe any lifestyle changes experienced by the injured person and his or her family.

Describe any special concerns. Please describe any special concerns.

How did you hear about this Web site? How did you hear about this Web site? Please choose one.

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Marcotte Law Firm
45 Merrimack Street
Suite 410
Lowell, MA 01852

Phone: 978- 458-1229
Fax: 978-453-4468

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The Marcotte Law Firm is based in Lowell, Massachusetts. We represent clients throughout Northern Mass and Merrimack Valley (including Lawrence, Dracut, Chelmsford, Tewksbury, Westford, Billerica, Tyngsboro, Methuen, Andover, Middlesex County and Essex County) and Southern New Hampshire (including Windham, Nashua, Salem, Pelham, Hudson, Londonderry, Derry, Hillsborough County and Rockingham County).

Lowell Massachusetts Marcotte Law Firm Injury Attorneys Video

Personal Injury Intake Form