2615 Pan American Life Center
601 Poydras Street
New Orleans, Louisiana 70130
 
Offshore Injuries and Deaths
Boat and Vessel Injuries
Drilling and Workover Operations
Inland Water and River Injuries
Personal Watercraft Injuries
Maritime and Admiralty Acts and Legislation
 

Tell Us About Your Case:
 
 

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 their 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?
       
   
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From our law offices in New Orleans, Louisiana, our personal injury lawyers serve clients along the Gulf Coast, from Texas to Alabama. We can help clients in Florida, Mississippi, and anywhere in the US in matters of maritime law and serious personal injury.

For information on how we can help you,
Contact our office today: 504-588-1500
Toll Free: 1-800-960-1526