Contact Us

Gallot Law Office
Personal Injury Attorney
203 South Vienna Street
Ruston, LA 71270
Phone: (318) 251-8480
Fax: (318) 251-8481

Personal Injury Form

*Name:
*Address:
*City:
*State:
*Zip:
*E-mail address:
*Home Phone:
Business Phone:
Cellular or Pager:
Facsimile:
Who was injured?
If "Other ", please describe:
Injured person's name (if different from above):
Address:
City:
State:
Zip:
E-mail address:
Home Phone:
Business Phone:
Cellular or Pager:
Facsimile:
When did the injury occur?
Where did the injury occur?
Was this location the injured person's
If "Workplace," did the injury occur as a result of employment activities?
YesNo
If "Other," was this a road accident?
YesNo
If no, did the injury occur on another's property?
YesNo
If yes, who owns the property?
How did the injury happen?
What were the surrounding circumstances (weather, lighting, slipperiness, other)?
Were there witnesses to the injury?
YesNo
If yes, what are their names/contact information?
Were others involved or injured at the same time?
YesNo
If yes, what are their names/contact information?
Was there a police report?
YesNo
Did the injured person receive medical treatment?
YesNo
If yes, provide dates, locations, provider names, and details:
Is the injured person still receiving treatment?
YesNo
Was the injured person killed as a result of the accident?
YesNo
If yes, what was the date of his or her death?
Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:
Describe other losses resulting from the injury (lost wages, damaged property, other):
Where did you hear about this website?
 

NOTE: The use of the Internet for communications with the firm will not establish an attorney-client relationship and messages containing confidential or time-sensitive information should not be sent.