Negligent Security Contact Form

Name

Email Address

Phone Number

What was the date and time of your injury?

Do you have the address and description of the premises where your injury occurred?
Yes  No 

What happened during the attack?

Did you observe any security measures in place on the premises where you were attacked?
Yes  No 

Do you know of any witnesses to any stage of the incident?
Yes  No 

Do you have any physical evidence from the incident including torn clothing, injury photographs, etc.?
Yes  No 

Did you know your attacker(s)?
Yes  No 

Can you provide a physical description of them?
Yes  No 

Was a police report was filed, and if so, do you know the police department with which the complaint was filed, the detective or officer assigned to the case, the complaint or report number, or if statements were taken as part of an investigation?

Was there or is there a criminal case against your attacker?
Yes  No 

What do you know about the status of the criminal proceedings?

What injuries did you suffer in the attack?

When and where did you first seek medical attention?

What is your prognosis? Do you know yet if any of your injuries are permanent?

Have you missed work due to your injuries?
Yes  No 

Have you been contacted by anyone regarding your attack besides the police and the prosecutors' office?
Yes  No 

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