Law Offices of Randal L. Menard

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In order to determine whether you have a case, please complete the following CASE FORM. We will treat this information as confidential and will respond within 24 hours of receipt.

Name:
Address:
City:
State:
Zip:
Email:
Phone:

Please Detail your Question here:
Type of injury:
Date of injury:
Description of events that led to injury:

Number of People involved in accident:
Was an Emergency Medical Team deployed?	Yes No
If yes, give name of EMT responding:

Were the Police contacted/deployed?	Yes No
If yes, give name of Agency responding:
Officer on scene (Name/Badge Number):

Was a ticket issued?	Yes No
If yes, who received the ticket?

Was an accident report filed?	Yes No
If yes, what is the case number?	#
Do you have a copy of the report?	Yes No

Were there environmental/climate factors impacting this incident?	Yes No
If yes, explain:

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