[VLN-MVA] Dimopolous Law Intake Form

Case Type: (MVA)? *

Date of Accident *

Are you at fault for this accident? *

If YES, did you have any passengers?

Have you spoken with an attorney about this case? *

If YES, have you signed any documents?

Accident location: *

Description of the accident: *

Is there a police report? *

If YES, did anyone get cited?

If YES, who and for what?

If NO, did you exchange information with the other party?

Have you sustained any injuries? *

If yes, have you received any medical treatment?

Was your vehicle a total loss? *

Did either vehicle's airbags deploy? *

First Name *

Last Name *

Email *

Phone *