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Free Injury Incident Report

Please fill in the boxes and use the TAB key to move to each box.

Your Full Name:

Email Address:

Street Address: Apt./Unit:

City: State: Zip:

Home Phone Number:

Work Phone Number:

How would you like for us to respond to you:

What is the best time to reach you by telephone?

Type of personal injury:

Date you were injured:

Where were you hurt?

Describe the accident that caused your injury as thoroughly as possible:

Who do you believe was at fault?

What he/she did wrong:

Describe your injuries:

Was this injury permanent or temporary?

Have you contacted any other lawyer about your claim?

Did the lawyer agree to represent you?

Are you still being represented by this attorney?

Are you seeking representation or a second opinion?

Have you negotiated with any insurance company or any person involved in this claim?

Have any medical, funeral bills or lost wages been paid for by any of the following:

Worker's Compensation:
Medicare, Medicaid or any other government program?
Employer health plan:
Private insurance:

Do you have any questions that you would like answered?

Is there any other information or instructions you would like to provide us with?

Would you like to arrange an interview?

In the box below, please enter the word you see in the image above


* The Law Office of Jack L. Townsend, Sr., P.A. (Hereafter identified as The Firm)
provides this form for information purposes only. It is intended for use by those
individuals and entities that may become clients of The Firm and have legitimate
concerns of questions for the practice area of The Firm. This report is not a contract
for representation with The Firm. To become a client and have The Firm represent
your interest will require a written contract and Statement of Client's Rights to be
signed by the client and The Firm.


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