Do I Have a Case?

Have you recently been injured in an accident? We have made it easy for you to see if you have a potential claim for money damages for your injuries. Simply fill out the sections below in our innovative Free Case Appraisal and click the "SUBMIT" button. One of our experienced attorney will review the information and contact you within 1 hour if you submit this form between 9:00 a.m. - 5:00 p.m. Central Time or by the next business day if you submit after 5:00 p.m. Central Time. This form should take less than two minutes to complete.

If you prefer to speak to an attorney directly about your case, please call 1.866.335.8300 or 918.295.8300.

Please tell us your relationship to the injured person

Your relationship to the injured person Select One Self Spouse Parent Colleague Friend Other

If Other, please specify

Please tell us about the injured person
First Name		Middle Initial		Last Name
Street Address 1		Street Address 2
City		State		Zip Code (5 Digits)
Home Phone (XXX-XXX-XXXX) ( )   -		Work Phone (XXX-XXX-XXXX) ( )   -		Cell Phone (XXX-XXX-XXXX) ( )   -
Email Address		Date of Birth (MM/DD/YYYY) /  /		Gender Male  Female

Please tell us what happened
Date of Accident (MM/DD/YYYY) /  /
Type of Accident Select One A road accident An accident at work An occupational injury or disease An accident in a public place An accident in a shop or office An accident in someone else's home An accident caused by defective goods An accident caused by contaminated food
If Other, please specify
Driver or Passenger, if automobile, moped, or motorcycle accident? Driver  Passenger
Is injured person at fault? Yes No
Did the injured person lose his/her job, have unpaid time off, or lose work-related benefits as a result of the injury? Yes No
Is injured person currently out of work due to the accident? Yes No
Did injured person require surgery due to the accident? Yes No
Is injured person currently in treatment? Yes No
Please select the injury(ies) that the injured person received for each part of the body.
Head Select One Impaired vision Loss of sight		Left Arm/Shoulder Select One Cuts and bruises Sprain		Right Arm/Shoulder Select One Cuts and bruises Sprain
Left Hand Select One Cuts and bruises Sprain		Right Hand Select One Cuts and bruises Sprain		Torso Select One Back Injury 2nd-3rd degree burns
Reproductive System Select One Pregnancy complications Loss of pregnancy		Left Leg Select One Cuts and bruises Sprain		Right Leg Select One Cuts and bruises Sprain

Please complete this section if you are not the injured person
First Name		Middle Initial		Last Name
Street Address 1		Street Address 2
City		State		Zip Code (5 Digits)
Home Phone (XXX-XXX-XXXX) ( )   -		Work Phone (XXX-XXX-XXXX) ( )   -		Cell Phone (XXX-XXX-XXXX) ( )   -
Email Address		Are you 18 or above? Yes  No
Please enter any comments or suggestions in the area below

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