CALCULATE INJURY COMPENSATION Date of Incident: Was the accident your fault, or were you issued a ticket for the accident? Yes No Was a police report filed? Yes No Were you physically injured or in pain? Yes No Does anyone involved have vehicle insurance coverage? Yes No What types of injuries were sustained? (Please check all that apply) Whiplash Lost limb Brain injury Broken bones Spinal cord injury or paralysis Loss of life Did the accident cause hospitalization, medical treatment, surgery, or missed work? Yes No Is an attorney helping you with your claim or has an attorney already rejected your claim? Yes No State where the injury occurred: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Estimated Medical Bills: No Medical Bills Less Than $1,000 $1,000 $5,000 $5,000 $25,000 $25,000 $100,000 More Than $100,000 Please describe your injuries: First Name Last Name Phone Number Email Street Address City Zipcode City where the injury occurred My Claim Worth?