PERSONAL INJURY QUESTIONNAIRE
This questionnaire is designed to provide sufficient information to allow us to consider the merits of your claim and to advise you on what procedures to take and the probability of success. Do not send any documents at this time.
The questionnaire should be completed by the victim of the incident. If the victim is a minor (under 18 years of age) the questionnaire should be completed by a legal representative, usually the parent, who will be filing the claim on behalf of the minor.
 Once completed, this information will be considered confidential and will only be made available on a need to know basis.
 If you require more space to reply, please use the space provided at the end of this form.
 Be as specific as possible, street, city, state.
 If you sustained a visible injury, such as bruising, swelling, burn or scarring, it would assist us if you photograph, while the injury remains visible. We recommend that you keep a journal of the treatments received and take regular photographs to show the progress of the symptoms and recovery.