Contact Us

Personal Injury Case Evaluation Form

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Who was injured?

If "Other," please describe:

Injured person's name (if different from above):

Address:

City:

State:

Zip:

E-mail address:

Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

When did the injury occur?

Where did the injury occur?

Was this location the injured person's

If "Workplace," did the injury occur as a result of employment activities?
Yes  No 

If "Other," was this a road accident?
Yes  No 

If no, did the injury occur on another's property?
Yes  No 

If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?
Yes  No 

If yes, what are their names/contact information?

Were others involved or injured at the same time?
Yes  No 

If yes, what are their names/contact information?

Was there a police report?
Yes  No 

Did the injured person receive medical treatment?
Yes  No 

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
Yes  No 

Was the injured person killed as a result of the accident?
Yes  No 

If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

Where did you hear about this website?

 

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McAllister, Hyberg, White & Cohen, P.C.
2111 New Road, Suite 105 Northfield, NJ 08225
TEl: (609) 407-1000 Fax: (609) 407-1010 Toll-Free: (888) 407-4077

207 S. Main Street, Cape May Court House, NJ 08210
TEl: (609) 463-1515

The lawyers at McAllister, Hyberg, White & Cohen, P.C., have an average of over 28 years of experience assisting clients throughout southern New Jersey, including the cities of Northfield, Atlantic City, Cape May, Hammonton, Ocean City, Somers Point, Egg Harbor Township, Galloway, Toms River, Camden, Woodbury, Bridgeton, and Mt. Holly. Our attorneys also represent clients throughout Atlantic County, Cape May County, Camden County, Ocean County, Gloucester County, and Cumberland County in personal injury, workers' compensation, and employment law matters.

*Certified by the New Jersey Supreme Court as a Workers' Compensation Law Attorney.

**Certified by the New Jersey Supreme Court as a Civil Trial Attorney.