911 Call, Police Report, Death Certificate Form

Instructions

Read each section carefully and answer to the best of your knowledge. Providing the information below will allow us to quickly investigate the case before important evidence is deleted or lost.

911 calls provide a snapshot into what was happening at the time the injury occurred long before any lawsuit was contemplated and lawyers were involved. They are the real-time record of what happened. Unfortunately, 911 calls do not last and are often deleted months after they are created.

Not all cases generate a police report. In fact, in the clear majority of cases, the police are never asked to investigate. But when the police are contacted, those investigations can be critical to proving the case.

If you have a copy of the death certificate, we ask that you provide us with an original copy. But we would also like you to provide us with this information as we may need several copies throughout the course of the lawsuit.

911 Call, Police Report, Death Certificate

Your Information

Who you are, what case this involves

My First Name *

My Last Name *

Case *

Name of the injured person

Case ID

Injured Person's Social Security Number

We will need their social security number in order to obtain important information for their case.

911 Call

Was 911 called? *

Date of call: *

The date of 911 call we are looking for was when the main injury occurred or when it was first discovered.

Time of call (approximate):

Name of the facility where the call was made: *

Name of the nursing home, assisted living facility, rehab facility, etc.

Facility Address

Street Address

Apt. No. / Suite No.

City

State/Province

Zip/Postal

Country

If you do not know the full address, fill out the sections you do know.

Why was 911 called and who placed the call?

Describe the reason the nursing home gave for calling 911, if known. If you know who made the call, list them in this section.

Notes (Any additional information.)

Was this the 911 call that led to found out about the serious injury which we are investigating? Were there multiple 911 calls for the same injury? Or add anything that would be helpful for us to know.

If you are human, leave this field blank.