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Personal Injury Claims Registration

Personal Injury Claims Registration

At Antonucci Law, our accident lawyers balance extensive legal experience, skill, and genuine compassion to help people just like you set things right.

Call (908) 747-4477 or submit the details below of how you were injured and to schedule a free, no-risk case assessment.

Personal Injury

Are you a Medicare Recipient?
Yes No

Are you a Medicaid Recipient?
Yes No

Health Ins Carrier:

Motor Vehicle Accidents Only

Do you have Automobile Insurance?
Yes No
(if no, fill the following details)

Do you reside in a household with an insured vehicle?
Yes No

(if yes, fill the following details)

You will be requested to provide a copy of your insurance declaration page.

Do you have photographs of damage to either vehicle?
Yes No

Were you wearing your seat belt?
Yes No

Trip/Slip & Fall Accidents Only

Names/Addresses of Witnesses:

Was a police report or incident report prepared? Yes No

Defendant's Insurance

Have you been contacted by the insurance carrier of the party at fault? Yes No

If yes, provide the following:

Did you provide a statement? Yes No

We recommend that you refrain from having any further contact with the defendantâ€™s insurance carrier.

Injuries Sustained

Medical Treatment

Was an ambulance called to the scene? Yes No
(if yes, fill the following details)

List the names and addresses of all hospitals, physicians, and medical facilities from whom you received medical treatment:

Diagnosis (if known)

Treatment Received

Surgery: Yes No Proposed

Physical Therapy

Injections: Yes No Proposed

Lost Wages:

Did you lose time from work as a result of your injuries?
Yes No

Prior Injuries

Did you ever injure the same body parts before?
Yes No

Did you ever injure the same body parts before or after the work accident?
Yes No

If yes, provide diagnosis:

Names and addresses of prior physicians:

I understand that the answers I provide will be used to prepare my case, and if I am not completely honest, it will negatively affect the results of my case.

Call today for a free consultation (908) 747-4477 FREE CONSULTATION

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Certified Civil Trial Attorney

"A significant part of my success as a trial attorney, comes from the recognition that empathy and compassion are equally as important as my knowledge of the law and experience in the courtroom." - Stacey Antonucci

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