I was a victim in a(n): —Please choose an option—Automobile AccidentTruck or Semi AccidentMotorcycle AccidentRideshare Accident (Uber or Lyft)Pedestrian or Bicycle AccidentOther injury or Accident Please describe: Did "wrongful death" occur? —Please choose an option—YesNo This was work related: —Please choose an option—YesNo When did it happen? —Please choose an option—In the last 30 days1-6 months ago6-12 months agoOver a year ago Were you injured in the accident? —Please choose an option—YesNo Who was involved in the accident? —Please choose an option—MyselfSomeone else How do you know the injured person? I have taken the following action regarding my case: —Please choose an option—No action taken yetI saw a doctorOthers Please explain: I was at fault: —Please choose an option—NoPassengerYes Did you go to the doctor? —Please choose an option—YesNo
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