1.  Were you involved in an accident?

If yes, please explain how and where the accident happened below:

2.  Were you injured?

If yes, please describe in detail the nature and extent of your injuries below:

3.  Did you report the accident or injury?

If yes, describe who you reported the accident or injury below:

4.  Was there any kind of police report taken following the accident or injury?

If yes, what police agency took the report:

Did you give a statement?

5. Do you have any form of insurance?

If yes, what company and what is the name of your insurance representative:

6. At the time of the accident were you employed?

If yes, who was your employer and what kind of work did you do?

7. What was your salary or rate of pay?

8. Did you miss work because of your accident or injury? If so, how much?

9. Have you filed a workers compensation claim related to your accident or Injury?

10. At the time of the accident or injury were you married?

11. What was your living situation?

12. Did you have children at the time of your accident or injury?

If yes, please list ages of the children:

Please read this, it is important:

By submitting this potential client intake form you are not establishing an attorney-client relationship with GRT. We are making no commitment to take your case and we are not taking any action on your behalf. In the event that we might be interested in taking your case we will communicate with you further and gather more information. No attorney-client relationship will exist if and until you and GRT execute a comprehensive attorney-client retainer/fee agreement.

Note: GRT does not offer free or no cost consultations or evaluations in most cases.