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):


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