Is the claim for you or a loved one? *

Self

Loved One

Did your love one pass away? *

Yes

No

What day did they pass away? *

What is the name of your loved one? *

What's your relationship with your loved one? *

I'm their spouse

I'm their child

I'm their parent

Other

Which wildfire were you affected by? *

Eaton Fire

Palisades Fire

Other

Were you or your loved one forced to evacuate? *

Mandatory Evacuation

Optional Evacuation

Did not Evacuate

Business Owners: Please estimate the loss of revenue/income due to business interruption from the fire.

Business Owners: Please provide the name and address of the business that was damaged. (If more than one address, we will gather this information during full intake).

Home Owners: Please estimate the value of the property that was damaged by the fire.

Home Owners: Please provide the address where the property damage occurred. (If more than one address, we will gather this information during full intake). *

Is there insurance on the property that was damaged? *

Yes

No

Have you made a claim for insurance? *

Yes

No

Have you been denied coverage or underpaid for your claim? *

Yes

No

Please estimate the amount of personal income loss.

More than $50,000

$25,000 to $49,999

$10,000 to $24,999

Less than $10,000

Did you or your loved ones experience any physical injuries? *

Yes

No

What kind of injuries did you and your loved ones experience? *

Would you like to add any additional information that will help us determine if the case qualifies for compensation? *

Yes

No

Please add any additional information that will help us determine if you qualify.

Are you working with another law firm regarding this case? *

Yes

No

Instant Qualifying Quiz Done

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First Name *

Last Name *

Phone *

Email *

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