Name
Email Address
Phone Number
Were you the victim of the drunk driving accident? Yes No
If not, are you related to that person? Yes No
How?
When and where did the drunk driving accident occur?
Were you a passenger, driver, or pedestrian? Yes No
How did the accident occur?
Was a police report generated after the accident? Yes No
Do you know if a drunk driving arrest was made? Yes No
Do you know the names of any witnesses to the accident? Yes No
What injuries were sustained as a result of the accident?
Are you currently receiving medical treatment as a result of the accident? Yes No
Have you discussed this matter with your own insurance representative? Yes No
Have you discussed this matter with any insurance representative or attorney representing other parties involved in the accident? Yes No
How has this accident affected your overall life experience and well-being?
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