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ACCIDENT INTAKE FORM

Please check all that apply:

ACCIDENT

Were you the Driver or Passenger?
Did the other driver receive a citation or ticket?
Were there any witnesses?

VEHICLE INSURANCE INFORMATION

Check all that apply at the time of the Accident:

Your Insurance Claim Information

Was a claim filed under your policy and insurance?

Other Driver's Insurance Claim Information

Was a claim filed under the other driver's policy and insurance?

BODILY INJURY, TREATMENTS, AND MEDICAL PROVIDERS

Medical Providers

If you have treated to date for the related accident, please check all that applies:

Please identify all of the medical providers you have treated with to date below:

Your Health Insurance Information

Please check all that applies to your health insurance status at the time of the accident:

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.

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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.

Submission Successful

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