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About
Lawyers
Doctors
Patients
Charitable Contributions
(214) 730-4993
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Patient's Attorney
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Contact Person
Email
Phone
Handling Attorney
Handling Attorney Email
Status of Claim: Is case in suit?
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No
Please provide the County Cause Number:
Patient Information
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Armed Forces Americas
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Injury treatment is needed for:
Type Of Claim:
Auto Collision
Premises Liability
Workplace Injury
Description of the event:
Location of the event:
Property damage paid by 3rd party carrier?
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No
If yes, how much?
Is there a police report?
Yes
No
If yes, please attach copy
Max. file size: 300 MB.
Has the third party carrier accepted liability?
Yes
No
Description of event:
Location of event:
Dangerous condition causing injury:
Facts showing responsible party had prior knowledge of dangerous condition:
Description of event:
Location of event:
Type of claim:
Third Party Liability
Nonsubscriber
Does employer have workers comp?
Yes
No
If YES and benefits have been paid, amount paid:
At-Fault Party Information
Step 3 of 3
At-Fault Party
Insurance Company
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