Swanson Gardner, P.L.L.C.
4512 Talbot Road South
Renton, WA 98055-6216
Phone:
(425) 226-7920
Washington State Toll Free:
(800) 427-5452
Fax: (425) 226-5168
Email | Map & Directions

Contact Us

 

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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Swanson Gardner, P.L.L.C.
4512 Talbot Road South, Renton, WA 98055-6216

Phone: (425) 226-7920

Western Washington State Toll Free: (800) 427-5452

Fax: (425) 226-5168

Email | Map & Directions

From law offices in Renton, WA, near Seattle, our personal injury lawyers help people throughout western Washington, including residents of Tukwila, Kent, Bellevue, Auburn, Federal Way, Enumclaw, Maple Valley, Issaquah, South King County, and elsewhere in the Sea-Tac area.