Slip and Fall Contact Form

Name

Email Address

Phone Number

Where and when did you fall?

Why were you in that location?

Did anyone invite you to enter the property?

Who owns the property in question?

Were you carrying anything in your hands at the time of your fall?

What caused you to fall?

Do you know how long that physical condition or hazard had existed on the property?

Had you looked at the condition or hazard, could you have seen it? Had you seen it, could you have avoided it?

Did anyone acknowledge having seen the condition prior to your fall?

Do you know what or who created the condition?

Did you fall forward or backward?

Did your feet go out from underneath you? Describe the nature of your fall.

Did the fall cause you to suffer any physical or mental injuries?

When did you begin medical treatment for your injuries?

Have you missed work because of your injuries?

What is your diagnosis and prognosis?

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