FELA Questionnaire

*Name:

Street Address:

City:

State:
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Zip:

Phone:

Fax:

*Email Address:

Location of accident:

Date of accident:

Who was injured?

How did the accident happen?

What were your injuries?

Were there any defective conditions which contributed to the accident?
Yes  No 

How could this accident have been avoided?

Who is your employer?

Have you given a statement either signed or recorded?
Yes  No 

Were there witnesses to the accident?
Yes  No 

Were there any witnesses who are not employed with your company?
Yes  No 

Has anyone from your employer indicated that you were at fault?
Yes  No 

Did anyone take any photos or video of the scene?
Yes  No 

Have you discussed this matter with any other attorney or law firm?
Yes  No