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Joseph E. Cantini
David Brannen
Pascale Julien
Mathieu Picard
Jean-Daniel Comeau
Scott McGirr
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Get a Free Injury Claim Consultation
Would you like more information about your legal options? We'll get back to you quickly for a consultation concerning your case.
We've tried to keep this form as short and simple as possible but you can also choose to
contact us by e-mail
or by phone at 1-800-606-2529.
Step 1 of 5 - About You
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Street Address
*
City
*
Province
*
New Brunswick
Nova Scotia
Prince Edward Island
Postal Code
Phone
*
Email
Preferred contact method
Phone
E-mail
Who was injured in the accident?
*
Myself
Family members, but not myself
Family members and myself
My friends and myself
If you were involved in an accident with friends, you should each fill out this form individually. Since you are not related, each case must be handled separately.
Your name
*
First
Last
Your date of birth
*
DD
MM
YYYY
Name of Family Member 1
*
First
Last
Family Member 1's relationship to you (Spouse, Parent, etc.)
*
Name of Family Member 2
First
Last
Family Member 2's relationship to you
Name of Family Member 3
First
Last
Family Member 3's relationship to you
Were there more people involved? Please name them here.
Do you currently have a lawyer?
*
Yes, I have a lawyer
No, I do not have a lawyer
Date of the accident
*
DD
MM
YYYY
Time of the accident
:
HH
MM
AM
PM
Location of the accident (City and Street)
*
Please provide a brief description of the accident
*
Were you in a vehicle?
*
I was in a vehicle
I was a pedestrian / riding a bicycle
Make, model and year of vehicle
Were you the driver, or a passenger?
*
I was driving the vehicle
I was a passenger
Were you the owner of the vehicle?
Yes, it was my vehicle
No, it was not my vehicle
Who was the owner of the vehicle?
Were you wearing a seatbelt?
*
I was wearing a seatbelt
I was not wearing a seatbelt
What are your injuries?
*
Did you have pre-existing injuries or conditions before the accident?
*
Yes, I already had injuries or conditions before the accident
No, I did not have any injury or condition before the accident
Please describe your pre-existing injuries:
Did your previous injury affect your ability to work, perform household duties, or your usual daily activities?
Yes, the injury affected my daily activities
No, the injury did not affect my daily activities
Have you seen a doctor or health practitioner (Physio, etc.) since the acident?
*
Yes, I have seen doctor or health practitioner since the accident
No, I have not seen a doctor or health practitioner since the accident
Please list the types of health professionals you have visited, and how often you have seen each one since the accident
Have you received treatment for the injuries you sustained in the accident? (Medication, Home remedies, etc.)
*
Yes, I have received treatment
No, I have not received treatment
Please list the treatments as well as how often you received them
Are you currently receiving short-term or long-term disability benefits?
*
Yes, I am receiving disability benefits
No, I am not receiving disability benefits
Have your injuries from the accident affected your ability to work, perform household duties, or your usual daily activities?
*
Yes, the accident has affected my daily activities
No, the accident has not affected my daily activities
Have you applied to your own insurance for accident benefits?
*
Yes, I have applied to my insurance for benefits
No, I have not applied to my insurance for benefits
Which benefits have you received to date?
Are you entitled to health care insurance? (Ex.: Blue Cross)
*
Yes, I have health insurance
No, I do not have health insurance
What is your employment status?
*
Employed
Unemployed
Retired or Student
Other
Please describe your employment status
Name of your employer
Your job title
Type of duties performed
Do you have more than one employer?
Yes, I have more than one employer
No, I have one employer
Please enter your other employers' information (name, your job title, type of duties performed)
Hours worked per week
Salary or hourly wage
Last year's annual income (before taxes)
Have you lost any time from work due to the accident?
Yes, I have lost time from work
No, I have not lost time from work
When, and for how long, did you lose time from work?
Have you returned to work since your time off?
Yes, I have returned to work
No, I have not returned to work
Are you performing the same job duties you did before the accident?
Yes, I am performing the same job duties
No, I am not performing the same job duties
How were you referred to our firm? (Friend, family member, other lawyer)
Comments
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Cantini Law Group
Personal Injury Lawyers since 1987 | Moncton, Halifax & Charlottetown
