Evaluation Form - Tragic Injury

Do You NEED HELP with (Select all that apply):*
- FREE Rental Car?
- Property Damage Bills?
- Medical Treatment?
- Medical Bill Reduction?
- Medical Transportation?
- Lost Wages from Missing Work?
Do you need Resources for Managing a Tragic Injury from an Auto Accident?*
- Yes
- No
In less than 3 minutes, this FREE Tragic Injury Evaluation Guide is designed to:
- Provide FREE Information Resources for Managing the Tragic Injuries from Auto Accidents
- Evaluate the Value of the Tragic Injury for FREE
- Offer Assistance in Legally Recovering the Value – NO UP FRONT COST!

How recent was your tragic injury accident?*
- Less than 3 months ago
- More than 3 months ago
You Must Consult with a Local attorney!

Do You Have a Incident/Police Report or Police Contact for Your Accident?*
- Yes
- No
Describe the Other Vehicle (check one):*
- Motorcycle [1, 2 or 3 wheel vehicle]
- Car/Passenger Vehicle
- Truck [Pickup]
- Commercial Vehicle [18-wheeler, Box Truck]
You Must Consult with a Local attorney!

Does the Police Report or Police Officer put Another Person AT-FAULT for the Accident?*
- Yes
- No
You Must Consult with a Local attorney!

Which Situation Describes Your Injuries? (check one):*
- Tragic – My Loved One or My Passengers or Myself Required a Hospital Stay or Passed Away
- Severe - My Loved One or My Passengers or Myself Required Immediate Medical Attention
- Serious - My Loved One or My Passengers or Myself Required some Medical Attention

Which Situation Describes Your Property Damage? (choose one):*
- Tragic – My Property is a Total Loss
- Severe - My Property Repairs are going to be very costly, I will need major assistance.
- Serious - My Property can be Repaired, I will need minor assistance.

Describes Your Need for Legal Help (choose one):*
- Tragic Injury – High Property Loss, need trial litigation assistance
- Severe Injury – Costly Property Loss, needs major legal assistance.
- Serious Injury - Property Loss, needs professional legal assistance.
Will you be able to afford Litigation Expenses?*
- Yes, but only after I receive Help
- No, I need help Immediate Help with Litigation Expenses

Based on your 90% Tragic Injury Evaluation, you NEED professional Help! Complete this form to receive 100% Legal help from the RAWLAW team!
First Name*
Last name*
Best Phone*
Alt
Best Time to Call
Email*
Where did the Accident Occur?
City*
State*
Zip*
Date of Accident
MM slash DD slash YYYY
Police Report Number
Upload a pic of your ID
Max. file size: 512 MB.
Upload a pic of the 1st page of the police report
Max. file size: 512 MB.
Upload a pic of you or your vehicle
Max. file size: 512 MB.
i Agree, Acknowledge, Understand And Accept:
*
- By Checking this box, I AGREE, ACKNOWLEDGE, UNDERSTAND and ACCEPT the full terms of the (1) Non - Solicitation Acknowledgement, (2) Authorization to Disclose health Information and (3) Contingency Fee Agreement.
Signature*
Type Client/legal Representation Name
Date
MM slash DD slash YYYY

Free Tragic Injury Evaluation Form