Premises Liability Contact Form

Name

Email Address

Phone Number

Where and how were you injured?

When did you first realize or suspect you were injured due to a condition on the premises?

What was your purpose for being in that location?

Were you invited to enter the property?
Yes  No 

Who owns the property in question?

Is there another person or entity other than the owner who occupies the premises?
Yes  No 

Is there a management company responsible for maintaining the premises?
Yes  No 

If you were on the property for work purposes, what were your job duties?

What types of materials or substances would you work with on a regular basis?

Were you aware of the dangerous condition on the property prior to your injury?
Yes  No 

Do you know how long the condition had been in the same condition existed or substance been on the property?
Yes  No 

Did you notify anyone of the condition?
Yes  No 

Do you know what/who created the condition?
Yes  No 

When did you begin undergoing medical treatment for that condition?

What is your diagnosis/prognosis?

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