Submit a case

Fill out the accident victim's details below. Required fields must be completed for the case to be reviewed. Referring on behalf of a partner? Tag it with a partner email at the bottom.
Consent Certificate
Our own TrustedForm certificate is captured automatically when this form is submitted — no action needed. If the victim actually completed a different form (e.g. an affiliate's own landing page) that generated its own TrustedForm or Jornaya certificate, paste that certificate URL below so both are kept on file.
Victim information
Incident details
Must be within the last 12 months (360 days) to qualify.
Qualification questions
A case that fails any starred question will be flagged Not Qualified before it's sent for review.
Did the victim sustain any physical injuries as a result of the accident? *
Was the victim not at fault for the accident? *
Did law enforcement respond to and investigate the accident? *
Does the victim have a police report or case number confirming the accident and date?
Are the at-fault party's insurance details available, or does the victim have uninsured/underinsured motorist (UM/UIM) coverage? *
Did the victim receive initial medical treatment within 30 days of the accident? *
Is the victim currently receiving ongoing medical treatment at least once per month?
Has the victim received at least one follow-up medical treatment after the initial visit?
Was the victim's most recent medical treatment within the last 60 days?
Is the victim currently not represented by an attorney? *
Has the victim never been dropped by a law firm for this case? *
Has the victim's claim not been settled? *
Referring partner
New here? Enter your name and email above — a partner account request will be created automatically. Or request one directly →
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