Get Started

Personal Information

Full Name *

Email Address *

Phone Number *

Date of Birth

Spouse (if applicable)

Street Address

Apartment, suite, etc

City

State

ZIP / Postal Code

Employment

Job

Job Duration

Wage

Hours

Point of Contact

Phone

Address

Apartment, suite, etc

City

State

ZIP / Postal Code

Additional EmploymentIf you are currently employed at more than one job, please list your other jobs here with the same information provided above.

Accident Information

Date of Accident

Time of Accident

Weather

Were you driving for Lyft or Uber at the time of the accident?YesNo

Location of Accident

Police InformationPlease describe which police were present (state, county, local) and provide officer names.

Police ReportPlease provide the police report number (if available) and describe any charges filed.

WitnessesPlease describe what witnesses were present.

Client/Passenger PositionsPlease describe your placement in the vehicle and list any other passengers along with their placement.

Adverse Information

Adverse Party's InformationAdverse Name, Address, Telephone No., Adverse Vehicle Owner

Adverse Party's Automobile InformationMake of Adverse Automobile, Model, Year, Tag No., Color, Damage Location, Damage Amount

Adverse Party's InsuranceAdverse Owner’s Insurance Company: ________________________________________Policy No., Claim No., Adjuster’s Name, Adjuster’s Address, Adjuster’s Phone No., Fax No.

Client Vehicle Information

Your Automobile InformationMake of Adverse Automobile, Model, Year, Tag No., Color, Damage Location, Damage Amount

Was the vehicle towed?YesNo

Automobile InsuranceName of Owner, Owner’s Insurance, Amount, Policy No., Claim No.

Insurance Contact InformationAdjuster’s Name, Adjuster’s Phone No., Adjuster’s Fax No., Adjuster’s Address

Does Owner have PIP Coverage on his/her policyYesNo

Has the accident been reported to the owner's insurance company?YesNo

Medical Information

Hospital and/or Doctors SeenDid you go to the hospital? If so, what tests and what prognosis was reached? Did you see any doctors for the accident? Who?

Medical InsurancePlease describe your medical insurance by providing the name, policy no., and prior accidents/injuries.

Get Started

Welcome to the family.

Intake Form