Wildfire Lawsuit Questionnaire

Wildfire Lawsuit Questionnaire

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Complete Our Questionnaire

If you don’t have an answer for a specific field, please type “N/A” for not applicable.

  • Please enter your first name.
  • Please enter your last name.
  • Please make a selection.
  • Please enter your relationship to the person impacted.
  • Type of injury or loss -- please check all that apply
  • Please enter the DOB.
  • Please enter the date of death.
  • Please enter the impacted street address.
  • Please enter the city name.
  • Please enter the zip code.
  • Please enter the county name.
  • Please enter your primary phone number.
    This isn't a valid phone number.
  • Please enter your secondary phone number.
    This isn't a valid phone number.
  • Please enter your other phone number.
    This isn't a valid phone number.
  • Please enter your email address.
    This isn't a valid email address.
  • Please enter your email address.
    This isn't a valid email address.
  • Please make a selection.
  • Please enter the trust name.
  • Please indicate who else lived in the home.
  • Please make a selection.
  • Injuries
  • Please let us know how you are doing.
  • Please make a selection.
  • Please describe the injuries.
  • Please make a selection.
  • Please make a selection.
  • Please enter what condition you sought treatment for.
  • Please enter what treatment you were given.
  • Prior to the fire, did you or anyone in your family suffer from any of the following? Check all that apply
  • Please describe the treatment.
  • Please make a selection.
  • Please describe the details of the incident.
  • Please make a selection.
  • Please make a selection.
  • Please enter where your pets are now.
  • Property Damage
  • Please make a selection.
  • Please enter the name of your insurance carrier.
  • Please make a selection.
    If you have a copy, will you please send it to us?
  • Please make a selection.
  • Please make a selection.
  • Please make a selection.
  • Please enter when you were evacuated.
  • Please enter how many days you have been relocated.
  • Please enter where you have been staying.
  • Please enter the street address.
  • Please enter the city name.
  • Please enter the zip code.
  • Please enter the county name.
  • Please describe the details of the damage
  • Do you have any videos, photos or an inventory of your property prior to the fire? Check all that apply.
    If you have any of these items, please reserve them for our firm. Also, if you do not have an inventory of lost items, please begin creating one now.
  • Please enter how long you lived in this home.
  • Please make a selection.
  • Please enter your monthly rent payment.
  • Please enter the size of your home.
  • Please enter the value of your home.
  • Please make a selection.
  • Please describe the details of the damage
  • Please make a selection.
  • Please provide the type of vehicle(s).
  • Please make a selection.
  • Business Loss
  • Please make a selection.
  • Please describe the details of the business loss
  • Please make a selection.
  • Please make a selection.
  • Please enter the estimated loss to business revenue.
  • Employment
  • Please make a selection.
  • Please enter how many days of work missed.
  • Please describe the details of your employment
  • Please make a selection.
  • Please tell us how your family was impacted.
  • Please make a selection.
  • Please tell us how you found us.
  • Please make a selection.