Case Intake Form

Sample Case Summaries
Type Of Injuries
About Us

Sample Case Summaries
Type Of Injuries
About Us

Please complete the following form to provide details about your incident. A representative will review your submission and contact you regarding next steps.

Personal Information

First Name

Last Name

Phone Number

Email Address

State of Residence

Date of Incident

Case Type

Motor Vehicle Accidents

Premises Liability

Medical Malpractice

Catastrophic Injuries

Product Liability

Wrongful Death Cases

Mass Torts & Class Actions

Aviation Accidents

Intentional Torts & Assault Injuries

Were you injured

Yes No

Have you hired an attorney?

Yes No

Is there a police report?

Yes No Not Sure

Incident Details

Location of Incident-City

Select your city

Location of Incident-State

Fatal Car Accidents

Police Brutality or Excessive Force Resulting in Death

Negligent Security Cases (Crime Victim Injuries)

Describe the incident in detail

Injury Details

Describe your injuries

Did you receive medical treatment?

Yes No

Where did you receive treatment?

Are you planning to seek further treatment?

Yes No

Fault & Evidence

Who do you believe was at fault for the incident?

Were you cited or accused of causing the incident?

Yes No

Do you have any of the following evidence?

Work & Financial Impact

Are you unable to work due to the incident?

Yes No

Are you self-employed?

Yes No

Has your employer or a company (e.g., Uber, Lyft) taken action against your account/job?

Yes No

Legal Representation

Would you like assistance in finding legal representation?

Yes No

Call (470) 660-4463

"I didn’t know where to start after my accident, but LawyersNearMe.ai made it simple. Ava reviewed my case instantly and connected me with a great attorney the same day!"
– James R., Atlanta, GA

"So quick and easy! I answered a few questions, and within minutes, I was matched with a top lawyer. No endless phone calls—just fast, expert help!"
– Sarah M., Miami, FL

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Sample Case Summaries
Type Of Injuries
About Us

Sample Case Summaries
Type Of Injuries
About Us

Case Intake Form

Please complete the following form to provide details about your incident. A representative will review your submission and contact you regarding next steps.

Personal Information

Incident Details

Injury Details

Fault & Evidence

Work & Financial Impact

Legal Representation

"I didn’t know where to start after my accident, but LawyersNearMe.ai made it simple. Ava reviewed my case instantly and connected me with a great attorney the same day!" – James R., Atlanta, GA

"So quick and easy! I answered a few questions, and within minutes, I was matched with a top lawyer. No endless phone calls—just fast, expert help!" – Sarah M., Miami, FL

"I didn’t know where to start after my accident, but LawyersNearMe.ai made it simple. Ava reviewed my case instantly and connected me with a great attorney the same day!"
– James R., Atlanta, GA

"So quick and easy! I answered a few questions, and within minutes, I was matched with a top lawyer. No endless phone calls—just fast, expert help!"
– Sarah M., Miami, FL