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Wrongful Death Intake Form

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Who was injured?

If "Other," please describe:

Injured person's name (if different from above):

Address:

City:

State:

Zip:

E-mail address:

Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

When did the injury occur?

Where did the injury occur?

Relation between the location and the injured person:

If "Workplace," did the injury occur as a result of employment activities?
Yes  No 

If "Other," was this a road accident?
Yes  No 

If no, did the injury occur on another person's property?
Yes  No 

If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?
Yes  No 

If yes, what are their names/contact information?

Were others involved or injured at the same time?
Yes  No 

If yes, what are their names/contact information?

Was there a police report?
Yes  No 

Did the injured person receive medical treatment?
Yes  No 

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
Yes  No 

Was the injured person killed as a result of the accident?
Yes  No 

If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

Where did you hear about this website?

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Our trucking accident injury lawyers represent clients injured on all Arizona highways, including I-40, I-10, I-17, and U.S. 60. We handle truck accident injury and fatality cases in Phoenix, Ahwatukee, Apache Junction, Avondale, Carefree, Casa Grande, Chandler, Cottonwood, El Mirage, Flagstaff, Fountain Hills, Gilbert, Glendale, Goodyear, Kingman, Litchfield Park, Maricopa, Mesa, Paradise Valley, Peoria, Pinetop-Lakewood, Prescott, Queen Creek, Scottsdale, Sedona, Show Low, Sun City, Sun City West, Surprise, Tempe, Tucson, Verde Valley, Wickenburg and throughout Arizona.
Address

OFFICE: 361 East Coronado Road - Suite 101 :: Phoenix, Arizona (AZ) :: 85004-1525 :: 602.271.9344 :: EMAIL US

Address

What to Expect in an Initial Consultation
For many of our clients who have been injured in truck accidents, this is their first venture into the legal system. We have developed this page to let you know what to expect when you contact Harris, Powers & Cunningham for help. READ MORE

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