Form | lnjury.com

CALCULATE AUTO INJURY COMPENSATION

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Date of Incident: *

Date should be in the past

Was the accident your fault, or were you issued a ticket for the accident? * NO YES

Please indicate if the accident was your fault.

Were you physically injured or in pain? * NO YES

Please select YES or NO

Does anyone involved have vehicle insurance coverage? * NO YES

Please indicate if yes or not.

What types of injuries were sustained?
(Please check all that apply)

Whiplash

Broken bones

Lost limb

Spinal cord injury or paralysis

Brain injury

Loss of life

Did the accident cause hospitalization, medical treatment, surgery, or missed work? * NO YES

Please indicate if the accident caused hospitalization.

Is an attorney helping you with your claim or has an attorney already rejected your claim? * NO YES

Please indicate if is an attorney helping you with the case.

State where the injury occurred: *

Please select your state

City where the injury occurred: *

Please select your city

Estimated Medical Bills: *

Please describe your injuries: *

Please describe your case.

Your information is secure

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First Name: *

Please enter a valid first name.

Last Name: *

Please enter a valid last name.

Phone Number: * (xxx)xxx-xxxx

Please enter a valid phone number.

Email: *

Please enter a valid email address.

My claim is unique. The law firm may ask me for additional case details so the lawyer can appraise my claim value.