Construction Accidents Contact Form

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

Were you injured at a construction site?
Yes  No 

If not, are you related to someone who was injured at a construction site?
Yes  No 

Were you injured in the course of employment while working at the construction site? If so, what was your job title/job description at the time of the incident that gave rise to your injury? Who was your employer? Were you employed by a contractor/sub-contractor?

When did the incident giving rise to your injury occur?

How did the incident occur? What were you doing at the time? If you were working at the construction site, were you being supervised? Describe the "chain of command" on the site.

If you were working at the construction site, was an accident report generated by your employer after the incident?
Yes  No 

Was any other hearing or proceeding held?
Yes  No 

Do you know the names of any co-workers or other individuals who may have witnessed the incident?
Yes  No 

What injuries were sustained as a result of the incident?

Are you currently receiving medical treatment as a result of the incident?
Yes  No 

Have you discussed this matter with any representative of other parties involved in the incident, such as your employer or a construction company attorney?
Yes  No 

How have your injuries affected your overall life experience and well-being?

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