2900 Chamblee Tucker Road
Building 14, Suite 200

Atlanta, Georgia 30341

Please complete as much of form as possible. Thank you!

Contact information: Client

Prefix

First name *

Middle name

Last name *

Date of birth

Emails

Email Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

PrimaryDefault email false

Add email

Addresses

Street address

Country

City

State/Region

Province/Region

Zip/Postal code

Address type

PrimaryDefault address false

Add address

Phone numbers

Phone number

Type

PrimaryDefault number false

Add phone number

Bass Legal serves an international client base. What languages do you speak?

EnglishSpanish / Español / PanyòlCreole / Kreyòl AyisyenOther

Date of Accident

Describe the accident.

Which Police Department Responded?

Case or Accident Report Number

If you have a police or accident report, upload it here.

Add attachment

Choose file

This file could not be attached because it exceeds the 50MB limit.

Please choose a file.

Were you driving or a passenger?

Driver

Passenger

Is your vehicle drivable?

Yes

Wearing Seatbelt?

Yes

Describe your injuries.

Have you seen a chiropractor or other medical provider? If so, please list them here.

Describe the damage to your vehicle (location of damage, how much, etc.)

Did you go to the hospital? If so, which one.

Were you transported by ambulance? If so, which one.

Do you have health insurance?

Yes

If you have health insurance, list your provider here.

Do you have MedPay Auto Coverage?

Yes

Do you receive Medicaid and/or Medicare?

Yes

What questions do you have for Bass Personal Injury Attorneys?

Social Security Number

Currently Married?

Yes