Your Accident

How did the accident occur? *

Fell overboard

Slips, trips, or falls on the vessel

Caught in machinery

Injured by falling cargo

Something else

Was your accident related to the vessel’s maintenance or equipment? *

Yes

No

Did your accident occur in U.S. waters or under U.S. jurisdiction? *

Yes

No

Your Injuries

Were you injured in the accident? *

Yes

I’m not sure

I have no injuries

What type of medical care have you received? Select all that apply. *

Hospitalization

Surgery

Chiropractic care

Pain management

None yet

Which of the following best describes the injuries sustained? Select all that apply. *

Head injury / Concussion

Back or Spinal injury

Broken bones

Burns

Internal injuries

Loss of limbs

Your Claim

Have you missed work due to the injury? *

I have been out of work since my injury

I missed 1-2 days of work

I missed 1-2 weeks of work

I have not missed any work

Has the insurance company offered you a settlement? *

Yes

No

Did you accept the settlement offer from the insurance company? *

Yes

No

First Name *

Last Name *

Email *

Phone *

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