Daniel R Denton, PC | Injury Lawyers | Beaufort, SC | 843.524.9445

Accident/Injury Questionnaire


Please provide the following information to assist us with your case. Fields in RED are required.

Full Name
Street Address
City, State
Phone Number
Email Address
Date of Accident (dd/mm/yyyy)
Injured at Work?
Were you operating a vehicle or machinery?
Was a police or employer incident report made?
In the report, who was found at fault?
Was the incident created by a hazardous working condition, faulty machinery, or by the act of another?
Please describe what happened. Also, please include your injuries and the injuries of others.
Did you sign any of the following?
Amount of financial loss to date (salary loss, medical costs, other)?
Have you or your family suffered other harm from these incidents? Please describe.
Did accident result in a disability that creates special needs at your job? Please describe.
Any other questions or concerns?

Nolo Homepage