Dan Denton | Attorney at Law | Beaufort, SC | 843.524.9445

Accident/Injury Questionaire


December 27th, 2007

Please provide the following information to assist us with your case.

Full Name
Street Address
City, State
Phone Number
Email Address
Date of Accident (dd/mm/yyyy)
Injured at Work?
Yes
No
Were you operating a vehicle or machinery?
Yes
No
Was a police or employer incident report made?
Yes
No
In the report, who was found at fault?
Was the incident created by a hazardous working condition, faulty machinery, or by the act of another?
Yes
No
Please describe what happened. Also, please include your injuries and the injuries of others.
Did you sign any of the following?
Waiver
Release
Arbitration Agreement
Other Agreement
None of the above
Amount of financial loss to date (salary loss, medical costs, other)?
Have you or your family suffered other harm from these incidents? Please describe.
Did accident result in a disability that creates special needs at your job? Please describe.
Any other questions or concerns?