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Premises Liability Questionnaire

Name
Mailing Address  
      Street Address
      City 
      State
      Zip
E-Mail Address
Phone Numbers
Name of Negligent Party (Person or corporation that caused accident and injury)
Date of Injury
Where Injury Happened
Describe How Accident Happened
e.g. car crash caused when other person ran red light, bricks fell from unprotected construction site and hit me in head, tool box fell off high shelving in store, etc.
Details of Injury and Damages


e.g. I needed surgery for ______, describe other medical treatment and expenses, I missed __ months of work, I am able (or not able) to return to my old job, my car was totaled, etc.
When to call & further contact
 
 

 
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