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Car Accident Related Brain Injuries: Every year, two million Americans will sustain a serious brain injury. Additionally, car accidents are among the leading causes of head and brain injuries. A brain injury can occur when the head has been struck--or strikes a foreign object, such as a windshield or steering wheel. Subsequent complications may be caused by a lack of oxygen, bleading of the brain, swelling, or rising pressure on the brain.

Depending on your state, brain injury victims have the right to seek monetary compensation to help cover medical bills, compensate for pain and suffering and provide for lost income potential. If you or someone you know has suffered brain damage, as a result of the negligence of another, you may be entitled to monetary compensation. Please fill out the "Brain Injury" consultation form below for a free evaluation of your brain injury claim by an experienced attorney. There is no cost or obligation for this service.

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First Name:	*
Middle Name:
Last Name:	*
Home Phone:	*
Cell Phone:
Work Phone:
Email Address:
Address:	*
City:	*
State, Zip:	* *
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Injured Person Information:

Date of Birth / Age: (ex. mm/dd/yyyy or 54)
Were you injured?	Yes No
If not, who are you inquiring on behalf of?

If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?

Is the person deceased?

Yes No

If deceased, what is the cause of death
as stated on the death certificate:

Date of Death: (ex. mm/dd/yyyy)
Was an autopsy performed?	Yes No
If not deceased, does the injury prevent you or the victim from working?	Yes No

If yes, when did you/victim stop working?
What is the approximate lost wages due to the injury?

Accident / Injury Information:

Date of Accident:	*
Time of Accident:
City where accident occured:	*
State where accident occured:	*

Estimated medical expenses (bills) to date:

Approximate money lost due to injury:
Did you go to the doctor?	Yes No
Did you go to the hospital?	Yes No

Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:

Please explain the full extent of the victims injuries:

Comments / Additional Information
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