Krafchick.com

Thank you for filling out this questionnaire. In order to determine if we can be of service to you, it will be useful for you to answer a few specific questions.

1.	Name:
2.	Address:
3.	Phone Number:
4.	Email Address:
5.	Social Security Number:
6.	What was the date of the collision?
7.	Where did the collision occur? (Street Location, City & State)
8.	Who was determined to be the at-fault party? Was this person working at the time of the collision? Who is/was their employer?
9.	Which insurance company insures the at-fault party? State the insurance limits if you know them.
10.	Do you have insurance coverage that covers you for the collision?	Yes No
11.	What are your PIP limits? (This information, if you have PIP coverage, is on your insurance card).
12.	What are the limits of your coverage for injuries due to uninsured motorists (known as UIM coverage)?
13.	Are you in a position to pay any of the costs incurred to develop your legal case?	Yes No
14.	Are you willing and able to travel to Seattle, or to travel to other areas nationwide, to be evaluated by experts that we refer you to?	Yes No
15.	Briefly describe any other facts about your case that you think we should know.