Please enable JavaScript in your browser to complete this form.Personal Injury Claim Support - Step 1 of 12Name *FirstLastPhone *Email *GDPR Agreement *I consent to having this website store my submitted information so they can respond to my inquiry.NextWhat type of motorcycle were you in? *StandardCruiserSport BikeTouringScooterCafé RacerOff-RoadMopedOtherPlease name the type of motorcycle.NextWhat state did the accident occur in? *AlabamaAlaskaArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWhich city did the accident occur in? *NextHow long ago did the accident happen? *Less than 30 days ago1-3 months ago3-6 months ago6-12 months ago12-24 months ago24+ months agoNextWere You The Driver, Passenger, or Pedestrian? *DriverPassengerPedestrianNextHow bad was your vehicle damaged? *Scratched/Fender BenderSeverely Damaged/Towed AwayTotal LossNextDo you know how much your accident is worth?I'm not sureI have a good estimateWhat is the estimate of your accident?NextWhat kind of vehicle was the other party driving? *Personal VehicleCommercial VehicleRideshare (Uber, Lyft, etc.)Government VehicleI'm Not SureWhich government entity did the vehicle belong to?What company did the vehicle belong to?NextWho was at fault? *It was my faultIt was the other drivers faultI'm not sureNextDid the other driver have insurance? *YesNoI'm not sureNextWhat type of medical treatment did u receive after the accident? *AmbulanceEmergency RoomDoctor's OfficeNoneIf you stayed at the hospital overnight, how long did you stay?1-3 nightsMore than 4 nightsNextAdditional comments or suggestionsGet assistance from a trusted attorney
