Personal injury is all we do, with over 20 years of experience.

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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The law office of Bruce A. Hagen, Attorney at Law, is located in the historic Marble House in Decatur, Georgia, and he represents residents of Decatur, Atlanta, Alpharetta, Roswell, Marietta, Jonesboro, Stone Mountain, Lithonia, Tucker, Snellville, Conyers, College Park, East Point, East Atlanta, Chamblee, Dunwoody, and Sandy Springs, Georgia.

DeKalb County • Fulton County • Gwinnett County • Cobb County • Clayton County

The Marble House, 119 N. McDonough Street Decatur, GA 30030

Telephone: (404) 522-7553 Fax: (404) 522-7744 Email: Contact the Firm

Bruce Hagen is "The People's Lawyer" as heard on 790 The Zone and the 2 Live Stews show.