CONFIDENTIAL INTAKE

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What Happened

Briefly describe what happened*

Were you working when it happened?

YesNo

Were you on a boat, ship, dock, harbor, or offshore?Vessel or company involvedWere there witnesses?

Injury Details

What injuries did you suffer?

Did you go to the hospital or urgent care?Do you have medical bills?

YesNo

Have you missed work because of this?Are you currently unable to work?

YesNo

Reporting & Prior Claims

Did you report this to your employer, Coast Guard, or another authority?

YesNoUnsure

If yes, when did you report it?Have you filed an insurance claim or lawsuit about this?

YesNo

Have you spoken with another attorney about this matter?

YesNo

Employment Details (Jones Act / Seaman)

Skip this section if it doesn't apply to your situation.

Employer nameVessel nameYour role / positionDates of employment

Urgency

Is there a deadline or court date?Do you need immediate help?

YesNo

What is your main concern right now?

Documents

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Tell us what happened.

Basic Contact

Case Type

What Happened

Injury Details

Insurance & Employer

Reporting & Prior Claims

Employment Details (Jones Act / Seaman)

Urgency

Documents

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