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Personal Injury Information
Personal Injury/Wronful Death FAQs
The Law Offices of
J. Randolph Ingram, II
102-F Commonwealth Court
Cary NC 27511
Phone: (919) 439-7886
Fax: (919) 467-0196
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Attorney J. Randolph Ingram, II is licensed to practice in the state of North Carolina and does not practice in any other state. His office is located in Cary, North Carolina. The firm does not seek to represent you based upon your visit or review of this web site and no attorney – client relationship is created by such visit or review. The material included in this website is not intended as legal advice. Readers should not act upon information contained in this material without professional legal counseling. This is an advertisement.

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Personal Injury Intake 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?
Yes  No 

If "Other," was this a road accident?
Yes  No 

If no, did the injury occur on another's property?
Yes  No 

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?
Yes  No 

If yes, what are the witnesses names/contact information?

Were others involved or injured at the same time?
Yes  No 

If yes, what are their names/contact information?

Was there a police report?
Yes  No 

Did the injured person receive medical treatment?
Yes  No 

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
Yes  No 

Was the injured person killed as a result of the accident?
Yes  No 

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?

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