VEHICLE INSURANCE INFORMATION
Your Insurance Claim Information
Other Driver's Insurance Claim Information
BODILY INJURY, TREATMENTS, AND MEDICAL PROVIDERS
Please identify all of the medical providers you have treated with to date below:
Your Health Insurance Information
Please provide your health insurance information for each entity, including,
(1) Name of Health Insurance,
(2) Group Name/Number,
(3) Policy Number, and,
(4) Claims Address and Telephone Number
ANY ADDITIONAL INFORMATION
The individual submitting the foregoing information affirms that said information is true and accurate and if submitting on behalf of another individual that full permission and consent has been expressly provided. THE SUBMISSION OF SAID INFORMATION DOES NOT CREATE A CLIENT-ATTORNEY RELATIONSHIP AND NO RELIANCE SHOULD BE ASSUMED AND THE ONLY MEANS THAT SUCH AN RELATIONSHIP IS CREATED IS BY EXPRESS, WRITTEN AGREEMENT OF THE RELATED PARTY(IES) AND THIS FIRM, THE EBRAHIMI LAW FIRM LLC, AND ANYONE WORKING ON BEHALF OF THIS FIRM.
Please allow 24-48 hours to respond. If you need prompt response, you are welcome to contact us by calling us at 678-835-7560.