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The Bernstein Approach
 

Slip and Fall

Step 2 of 3

Please tell us more about the injured person:

Injured person's first name: required field
Injured person's last name: required field
Address:
City:
State:
Zip:
Area code & phone number:
 - -
  Home Work Mobile
Age:
Gender: Male Female
______________________________

Please tell us about the slip and fall accident:
Date of accident:
Accident location - City:
Accident location - State:
What caused you to slip and fall?
Brief description of accident:
______________________________

Please tell us about the injury:
Broken bones? Yes No Unsure
If yes, which bones?
Hospitalized? Yes No
If yes, how many days?
Brief description of the injury:
Ongoing treatment? Yes No Unsure
If yes, please describe ongoing treatment:
   

required field = Required Why?

 
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