Admiralty Law Lawyers and Information
1-866-242-0905

Admiralty Law Case Review

1-866-242-0905

Contact Information
Fill out the following form or call 1-866-242-0905 24 hours a day, 7 days a week for a Free Case Review.

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First Name*
Last Name
Home Phone* - -
Work Phone* - -
Cell Phone* - -
Email Address*
Retype Email Address*
Street Address:
City
State/Zip
Injured Person's Information
The injured person is
First Name:
Last Name:
Home Phone: - -
Work Phone: - -
Cell Phone: - -
Email Address:
Street Address:
City:
State/Zip
Date of Birth
Sex Male  Female
Date of Incident
Location of Incident (city, state)
Type of accident
Please Describe your accident:
Type of Injury Sustained
Was the injured person on duty or working when injury occurred?
Yes
No
If yes, please list name of employer and occupation/job title
Was the injured person recognized as having "seaman status"?
Yes
No
Was there an accident report completed by the employer?
Yes
No
Do you or the injured person have a copy of the accident report?
Yes
No
Were there witnesses of the accident?
Yes
No
Do you or the injured person have witness statements regarding the accident?
Yes
No
In the accident report, was there a dangerous or unsafe condition that contributed or caused the injury?
Yes
No
If yes, describe:
In the accident report, was the vessel described or listed as being unseaworthy?
Yes
No
If yes, describe:
In the accident report, was the accident caused by or due to the action or lack of action of another person?
Yes
No
If yes, describe:
Did the injured person receive prompt medical attention?
Yes
No
Was the medical attention provided by the employer of the injured person or chosen by the injured person?
Employer Provided
Chosen by Injured Person
Please provide the name of the treating physician
Was the person hospitalized?
Yes
No
Please provide the name of the hospital
If released from the hospital, is the injured person still being provided ongoing treatment?
Yes
No
Please provide any additional information or comments
Do you or the injured person currently have an attorney for this claim?
Yes
No
a. I agree that submitting this form and the information contained within does not establish an attorney client relationship.
b. I agree that my information will be reviewed by more than one attorney and/or law firm.
c. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.
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