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Admiralty Law Case Review

Contact Information

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State/Zip	State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Injured Person's Information

The injured person is	me spouse parent relative friend
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State/Zip	State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Date of Birth	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 20072006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Sex	Male  Female
Date of Incident	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 20072006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Location of Incident (city, state)	State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Type of accident	Accident Type Fishing Vessel Accident Charter Vessel Accident Drilling Rig Accident Cruise Ship Accident Vessel to Vessel Collision Tugboat Accident Cargo Vessel Accident Tanker Accident Casino Ship Accident Commercial Fishing Boat Accident Steamship Accident Icebreaker Vessel Accident Barge Accident Dock Worker Accident other
Please Describe your accident:
Type of Injury Sustained	Injury Type Death Head Injury Spinal Cord Injury Broken Bones Paraplegia Quadriplegia Paralysis Amputation (loss of limb) Concussion Coma Laceration/Cuts Blindness (loss of vision) Deafness (loss of hearing) other
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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