Home » Automobile Collision Intake Guide
Name If Not The Injured Person
Phone If Not The Injured Person
How Did You Find Out About Us?
Have you talked to another lawyer or law firm?
Emergency Contact Name
Emergency Contact Phone
Date of Collision*
Description of Collision*
Is there a police report? If so, which agency and do you have a copy?
Was anyone cited?
Was the other driver insured? With whom?
Describe your injuries
Description of treatment
Estimated Medical Costs
Private health insurance?
Any pre-existing injuries or medical conditions?
Employment? Missed Work? Estimated wage loss?
Larry Wall Trial Law
121 S. Whittier St.
Wichita, KS 67207