Slip and Fall Accident Form - Initial Claim setup

Slip and Fall Accident Form

Below is a comprehensive form which will help you provide us with information required to evaluate your claim. By sending us this information, you will essentially be helping us create your initial file. When we contact you we will have a good deal of information on hand with which to help you.

If you are unsure of any of the required information, please contact us directly by email at attorneys@sokoloffandweinstein.com or by phone at 561-790-6788 or 561-790-4505.

*First Name:

*Last Name:

*Address:

*City:

*State:

*Zip Code:

*Contact Phone:

Other Phone:

*When is the best time for us to contact you?: Morning Afternoon Evening Any Time

EMail:

*Date of Accident:

*Was this accident work-related?:

Employer Name:

Employer State:

Briefly describe your accident:

*Are you currently seeing a doctor because of this accident?:

If so, what is your Doctor's name?:

Doctor's City:

Doctor's State:

Doctor's Phone:

*Do you have health insurance?:

If so, who is your insurer?:

Health Insurer phone (if known):

Sokoloff and Weinstein, P.A. Attorneys at Law - Email Us

ROYAL PALM BEACH OFFICE: 11440 Okeechobee Blvd - Royal Palm Beach, Florida 33411 - (561) 790-6788

VERO OFFICE: 2120 58th Avenue, #127 - Ryanwood Square - Vero Beach, Florida 32966 - (772) 486-6688

Injured? Not your fault? Sokoloff and Weinstein, P.A. Your South Florida Personal Injury Specialists Attorneys At Law Email us (561) 790-6788 11440 Okeechobee Blvd. Ste. 104 Royal Palm Beach, FL 33411 (772) 486-6688 2120 58th Avenue, #127 Ryanwood Square Vero Beach, Florida 32966