north carolinasouth carolina
Auto Accident Submission Form

   We are anxious to help you.  There are two ways you can contact us about your case.  You can either call us at 1.800.556.8404 to talk to one of our client service representatives or you can fill out the on-line form below and submit it to us from this website at any time.  After completing the form you may submit it by simply clicking on the I AGREE button after reading our necessary disclaimer. 



Personal Information

Your last Name   Your First Name   Your Gender  

Physical Address (Include City, State, Zip)  
Email Address    
Cell Phone (xxx-xxx-xxxx)   Home Phone (xxx-xxx-xxxx)   Work Phone (xxx-xxx-xxxx)  

 

Accident Information

Name(s) of Person(s) who caused accident:
Last Name: First Name Gender



People Injured Other than you:
Last Name First Name Relationship to you
Date of Accident:  
Was the other Vehicle a Government vehicle?
 
Place of Accident: City:
State:
Location:

Do you have any of the following?


Any evidence the other party was drinking/using drugs?
 
Was a tractor/trailer or large transport truck involved?
If Yes, name of the company that owned and/or operated the truck:  
How were you involved in the accident



 
Damage to your car:


 
Injuries - mark all that apply




 
Medical Treatment for your injuries - mark all that apply



 
Medical Costs


 
Lost Wages



 
Type of Accident:




 
Who was ticketed for accident?



 
Describe your injuries (optional):
Describe Accident (optional):
Do you have Underinsured/Uninsured Insurance Coverage?
 
If so, how much?

 
How many policies?  
How many different vehicles?  
Insurance Company:  
Were other persons injured by this accident?
 
If yes, were they in the same car as you?
 
Have you viewed our tutorial on auto accidents?
 
Are you presently represented by an attorney?
 

 

Disclaimer
WARNING:
If you are a Pre-Paid Legal Services, Inc. Member you may not use this method of seeking legal assistance. You must call the 1.800 number on your membership card. If you submit a request in this manner we will not be able to process you as a Pre-Paid Legal member which could result in significant delays.
     
Disclaimer:    
Before you can submit your case for potential review, you must read and agree to the following: "I understand that by submitting this information to MFWWC, I have not created an attorney/client relationship with MFWWC and that MFWWC has no responsibility to protect my interests in this matter in any way unless and until I enter into a signed, written fee agreement with MFWWC. I understand that MFWWC has no obligation to reply to this email and are not responsible for this matter. By clicking on the I Agree button below, I hereby submit my information on this basis and certify that I have read the GENERAL Disclaimer."  





  When you need legal help, we are here to serve you.