Who Are You Contacting Us For? *

I was injured in a motorcycle accident

A loved one was injured in a motorcycle accident.

I lost a loved one in a fatal motorcycle accident.

If you lost a loved one, what was your relationship to the person who passed away?

Spouse

Parent

Child

Sibling

Other

Name *

First Name

Last Name

Non-Work Phone *

(###)

###

####

Preferred Contact Method

Call

Text

Email

Date of Accident *

MM

DD

YYYY

Location of Accident *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Was the person injured the rider or passenger? *

Rider

Passenger

Not Sure

Was a helmet worn? *

Yes

No

Not Sure

What injuries were suffered? *

(Check all that apply)

Head Injury / Concussion

Broken Bones

Road Rash / Burns

Spinal Injury / Paralysis

Internal Injuries

Other

Was hospital treatment received? *

Yes

No

Is medical treatment still ongoing? *

Yes

No

Who do you believe caused the accident? *

(Check all that apply)

Another Driver (Car/Truck)

A Defective Part (Brake Failure, Tire Blowout, etc.)

Poor Road Conditions (Potholes, Gravel, Debris)

Other

Did police come to the scene? *

Yes

No

Not Sure

Was a police report filed? *

Yes

No

Not Sure

Did the police determine fault? *

Yes

No

Not Sure

Did the motorcyclist have insurance? *

Yes

No

Not Sure

Did the other side have insurance? *

Yes

No

Not Sure

Have you already spoken to an insurance company? *

Yes

No

Have you hired another attorney for this case? *

Yes

No

How did you hear about us? *

Friend / Family Member

Another Attorney

Event

Social Media

Internet Search

Other

I understand this free case evaluation does not create an attorney-client relationship *

Yes