Evaluation Form

Please provide as much information as you can so that Berg, Dye & Russell is better able to provide you the most accurate evaluation possible. Berg, Dye & Russell will respond to you within 24 hours.

Required Fields are indicated by an asterisk(*)


Mr. Mrs. Ms
Name *
Address
City *
Postal Code
Phone *
E-mail Address *
Age
How did you hear about Berg, Dye & Russell?
Names of Parties Involved:
When did your injury occur?
How was the injury caused?
What are your injuries?
Have you returned to work?	Yes No
If so, when?
Where are you employed?
What is your annual income?
What are your ongoing problems?
Have you applied for accident benefits (through your own auto insurer) or for other benefits (short term or long term disability benefits)?
What accident benefits have you received to date? What other benefits have you received to date?
Is there a shortfall between your income and benefits paid?
Who is your insurance company?
Do you know the name of the insurance company of any other party involved in your accident?
Please list expenses you have incurred as a result of your injuries.
Do you have a police report or a report from a Collision Reporting Centre?	Yes No
Please provide us with any other information you feel Berg, Dye & Russell needs to know at this time to assist with your evaluation.
Provide a list of the names, addresses and telephone numbers of all hospitals, doctors, etc., who have treated you as a result of this incident.