Intake form

Name *

Email address *

What type of injury did you sustain?

Please select at least one option.

Car accident

Slip and fall

Workplace injury

Medical malpractice

Product liability

Dog bite

When did the accident occur?

Where did the accident take place?

Have you received medical treatment for your injury?

What is the name of the insurance company involved?

What is your preferred method of contact?

Have you previously filed a claim for this injury?

How did you hear about WestCoastInjury?

Please select at least one option.

Search engine

Social media

Referral

Which service or services are you interested in?

Please select at least one option.

Car accident claims

Motorcycle accident representation

Truck accident cases

Additional questions or comments