MVAA Accident Settlement Form is designed to determine whether one of our Panel Professionals may be interested in consulting with you about your motor vehicle accident.

No MVAA Panel member is agreeing to represent or take your accident, or injury case at this juncture.  There is no cost or obligation on your part or for one or more of the MVAA Panel Members to review your accident information.

Please provide your personal information.

*Last Name
*First Name

Please provide the following contact information:

Street Address
PO Box
City	State
Zip Code
County
Work Phone
Home Phone
FAX
*EMail
URL

Enter the date of Incident:

-- mm/dd/yy

Type of Accident:

How did the Injury Happen?

Can you describe the injuries?

Any other comments?

This form is intended to assist the MVAA Panel with a preliminary evaluation of your case. Your personal contact information remains confidential until you agree on acceptance of your case.