LEVITTE LAW GROUP - MOTOR VEHICLE & TRANSPORTATION ACCIDENT WEBSITE

Old City Hall, 45 School St. Boston MA 02108 | Phone 617 227 1792 | Fax 617 227 9294 | Email | Levitte Law Group
 
Auto Accident Free Evaluation Form (* denotes required fields)
Title:  
 *First Name: M.I.: *Last name: 
*Address Street: 
*City: *State: Zip Code: 
Phone: (xxx xxx xxxx) Best time to contact you: 
Email: 
Is this inquiry is not for your self please tell us relationship to the person: 
If this inquiry is not for your self, please provide the person name: 
First Name: Last Name: 
Injured Date of Birth: (mm/dd/yyyy) 
Date of accident: (mm/dd/yyyy) 
Place of accident? City: State: 
Were you or they injured in an auto accident: 
What are the injuries: 
If other please describe the injuries: 
What happened: 
What type of medical treatment was received: 
Who was responsible for the accident: 
Did the police respond to the accident: 
Did anyone receive a ticket: 
Did the other driver have insurance: 
Do you have insurance: 
Do you currently have an attorney: 
Please briefly describe your legal or any other concerns: 

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