Jump To Navigation
Industrial Strength Law.206-448-7777

Workers' Compensation Intake Form

Personal Injury 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?

Was this location the injured person's

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'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 the witnesses 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?

The contents of this contact form are provided by and are the responsibility of the person posting the email communication. Your email will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. You acknowledge that any reliance on material in email communications is at your own risk.

Address

2033 Sixth Avenue | Suite 800 | Seattle, WA 98121 | 206-448-7777 | Map & Directions

At the Seattle, WA Law Office of James E. Sedney, we represent clients throughout Washington, including Bellevue, WA, Everett, Tacoma, Federal Way, Redmond, Kirkland, Woodinville, Bothell, Lynnwood, Edmonds, Shoreline, Mukilteo, Snohomish, Renton, Burien, Kent, Auburn, Tukwilla, King County, Snohomish County, Pierce County, Skagit County, Puget Sound, Pacific Northwest, and the East Side, Washington.

FirmSite® by FindLaw, a Thomson Reuters business.