Submit a Motor Vehicle Accident Case Here

Fill out the accident victim's details below. Required fields must be completed for the case to be reviewed.
Compliance notice — read before submitting This form must be completed by the accident victim. If a referral partner is submitting this form on the victim's behalf, they must provide a valid TrustedForm or Jornaya certificate URL generated from a separate, original form that the victim personally completed. The certificate must verify that the victim knowingly and voluntarily consented to submit their information and to be contacted by MVA Resolve, its partner law firms, and authorized intake centers regarding their potential legal claim. Any manually completed or proxy-submitted form that is not supported by a valid, independent TrustedForm or Jornaya certificate may be deemed non-compliant and disqualified. Submission of false, fabricated, or invalid certifications, or forms submitted without documented consumer consent, may result in lead rejection, non-payment, account review, suspension, or termination of the referral partnership.
Who is completing this form?
Is the accident victim personally filling out and submitting this form right now?
A referral partner filling this out manually on the victim's behalf must provide an independent TrustedForm or Jornaya certificate URL below, proving the victim's own separate, willing consent. Without it, this case will be disqualified and the partner account flagged for quality review.
Victim information
Incident details
Must be within the last 12 months (360 days) to qualify.
Qualification questions
Please answer these case evaluation questions truthfully and to the best of your knowledge. Your responses will help determine whether your case meets our partner law firms' pre-qualification criteria for legal representation.
Did the victim sustain any physical injuries as a result of the accident? *
Was the other party at fault for the accident? *
Did the police 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 7 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 30 days?
The victim is currently not represented by an attorney, Is that true? *
The victim has never been dropped by a law firm for this case, Is that true? *
The victim's claim has not been settled, Is that true? *
Referring partner
Tracked automatically by partner tracking link and/or click ID if present in the URL. No link handy? Enter your partner email below instead — either (or both) will attribute this case to you.
New here? Enter your name and email above — a partner account request will be created automatically. Or request one directly →
Consent