Steven Granberg, Attorney at Law, P.A.

Steven Granberg, Attorney at Law, P.A.

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Tell Us About Your Case > Personal Injury Questionnaire

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Personal Injury Questionnaire

Please note there is no limit to the amount of information you can enter. The boxes will scroll as necessary as you add additional information.

    Incident Information

  1. What happened - how were you injured? Please include date, time, location, etc.


  2. Is there a police report?
    Yes No

    If yes, do you have the report?
    Yes No

  3. Please try to describe your injuries in some detail.


  4. Provide the names, addresses and phone numbers of all medical doctors or providers who have ever treated you for these injuries.


  5. Please describe any work activities, household duties, hobby/recreation/sports, or any other activities that you had to give up or change because of your injuries.


  6. If you have lost income (wages, commissions, other earning opportunities) because of your injuries, please state the amount you have lost and how you calculated the amount.


  7. If you have incurred expenses because of your injuries (medical bills, higher car payments, etc), please state the amount of the expenses and how you calculated that amount.


  8. Please describe any other ways in which this incident has negatively affected you.

    Insurance Information

  9. Did you have insurance covering the injury?
    Yes No

  10. Did the negligent person have insurance covering the injury?
    Yes No

  11. Have you made any statements to any insurance investigator or adjuster?
    Yes No

    If yes, to whom and when?


  12. Please add any other information you feel is important.



WARNING: The privileged information transmitted via the form below is not secure or encrypted. If you feel uncomfortable providing any of the information below, please leave it blank. If you prefer, you may also provide this information via fax, telephone or by visiting our office. Submitting a questionnaire does not create an agreement by you or our office to provide legal representation on any matter.

 

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Steven Granberg - Attorney at Law, P.A.

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DISCLAIMER: All information on this website is general in nature and does not constitute legal advice. We take no responsibility for errors. Submitting a questionnaire does not create an agreement by you or our office to provide legal representation on any matter.
Email - Gail Stewart - Steven Granberg

3800 Osuna Road NE, Suite 1
Albuquerque, New Mexico 87109-4401
Phone: 505-244-3779
Fax: 505-245-8558