Wildfire Victim Intake Form

For Legal Purposes

Location: Los Angeles, CA

Full Name

Date of birth

Phone *

Email *

Address

State

Postal code

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Privacy Policy | Terms of Service

Property Information

Affected Property Address

Do You Own or Rent This Property?

Rent

Own

Type of Property

Residential

Commercial

Land

Insurance Information

Provider

Policy Number

Coverage Details

Wildfire Impact Details

Date of Wildfire

Did You Evacuate?

Yes

No

If Yes, Date of Evacuation

Was Your Property Damaged?

Yes

No

If Yes, Describe the Damage (e.g., destroyed structures, smoke damage):

Were You Injured?

Yes

No

If Yes, Describe the Injury (e.g., burns, smoke inhalation)

Did You Lose Personal Items?

Yes

No

If Yes, Describe Items and Estimated Value

Financial Impact

Lost Income Due to Wildfire?

Yes

No

If Yes, Describe

Out-of-Pocket Expenses (e.g., temporary housing, medical bills):

Type of Expense

Amount

$

Health & Emotional Impact

Did You Seek Medical Attention?

Yes

No

If Yes, Provide Details

Have You Experienced Emotional Distress?

Yes

No

If Yes, Describe (e.g., anxiety, PTSD)

Additional Information

Have You Filed an Insurance Claim?

Yes

No

If Yes, Provide Status of Claim

2. Do You Have Documentation (e.g., photos, receipts)?

Yes

No

If Yes, Describe or Attach Copies:

(Photos Receipts etc.)

3. Are You Interested in Joining a Lawsuit?

Yes

No

Authorization & Signature

I authorize Kings Justice Law to collect and use this information for legal purposes, including pursuing compensation for damages caused by the wildfire.

Clear

Date Signed

NEXT