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Date of Accident








Were You At Fault?*YesNo
Were You Injured in the Accident?*YesNo
Do You Already Have the Report?*YesNo
Did You Receive a Ticket/Citation?*YesNo
Did The Other Driver Receive a Ticket/Citation?*YesNo
Do you already have an attorney?*YesNo

***Notice of Authorization***By submitting this form or contacting the firm for an accident report: I hereby grant Merck Law, LLC or any representative thereof, authorization to use the information I have provided for the sole purpose of obtaining my police report for the accident date stated above. My private information is only to be used for this intended purpose and by granting this authority, I understand that no client/attorney relationship has been created or formed. I understand that Merck Law, LLC does not represent me until and unless I enter into a separate contractual agreement for representation with Merck Law, LLC following my free case and accident report evaluation. Merck Law, LLC agrees to use the provided personal information only for the purpose of obtaining the accident report and evaluating the merits of the case in the light of personal injury representation. I hereby request Merck Law, LLC or any representative thereof contact me for a free accident report review. I understand that Merck Law, LLC cannot contact me or provide me an accident report for various reasons, including if I have already obtained an attorney for this accident, and may not respond to my request. Merck Law, LLC reserves the right not to respond to submissions with or without cause. I understand that Merck Law, LLC may not be able to locate my accident report, including if the accident report is not available yet, and cannot provide me a free accident report if they cannot locate it. I want Merck Law, LLC or any representative thereof to discuss representation on my case with me if they think my case is one they would like to represent me on.
By Checking This Box I Agree To The Above Notice