Please carefully fill out this form to the best of your ability. We assure you these questions are necessary to make sure we can best evaluate your case to see if we can help you and your family. If you need assistance understanding any part of the form, do not hesitate to call or text us at (813) 926-0222 or email us at info@westchaselegalcenter.com. Your cooperation is crucial in documenting the accident and ensuring a smooth claims process.

Please be aware that completing this form does not create an attorney client relationship between you and Westchase Legal Center.

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Contact information: Auto accident victim

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First name *

Middle name

Last name *

Date of birth

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

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Addresses

Street address

Country

City

State/Region

Zip/Postal code

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Phone numbers

Phone number

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Tell us about you.

Contact information: Auto accident victim

Tell us about the accident.

Date of Accident

Location of Accident (example: "Intersection of 54 and Gunn Highway, Pasco County, Florida")

Were you the driver, a passenger, or a pedestrian?

Were you at fault for this accident?

Were you wearing a seatbelt at the time of this accident?

To the best of you ability, please describe in detail how the incident described in the complaint happened, including all actions taken by you to prevent the incident

Tell us about your injuries.

Please identify the areas of your body which were injured as a result of this accident.

To the best of your ability describe the injuries you sustained as a result of this accident.

Did you seek medical treatment as a result of this accident?

Were you transported by ambulance from the scene of the accident?

Tell us about your insurance coverages.

Do you have automobile insurance?

Do you have underinsured motorist coverage?

Are you sick of answering all these questions?

Have you been in contact with any insurance adjuster regarding this accident?

Tell us everything we forgot to ask.

Each accident is different, pleases let us know if there is anything you believe we need to know that was not requested above.