Mohen & Associates Law Firm

Personal Injury Case Form

First Name
Last Name
Address
City, Town
State
Zip
Phone
alt Phone
Fax
E-mail
Date of Accident
Location of Accident (Include City or Town)
Did the police respond to your accident?	Yes No
If so, do you have a police report?	Yes No
Were you examined or treated at a hospital emergency room?	Yes No
Were you hospitalized?	Yes No
Did you see a doctor as a result of your injuries?	Yes No
Are you currently under a doctor's care for injuries sustained in this accident?	Yes No
Did you lose any time from school or work?	Yes No
Description of Accident: (Please include a description of what caused your accident, and who was at fault.)

Describe Your Injuries:

For motor vehicle accidents, describe the damage to the vehicles:

MOHEN & ASSOCIATES LLP
480 Forest Avenue Locust Valley, New York 11560
Phone (516) 759-1212 Fax (516) 759-3234

Mohen & Associates LLP 480 Forest Avenue Locust Valley, NY 11560 Tel. (516) 759-1212 Fax. (516) 759-3234 e-mail: admin@mtlaw.com