Claimant Intake Form We collect this essential information about you as a Claimant and your claim to prepare disclosure requests. 1. Personal Information Full Name Phone Number Email Address Mailing Address 2. Incident Details Date of Incident Time of Incident Location of Incident Brief Summary of Incident 3. Insurance Company Information Insurance Company Name Claim Number (if known) Policy Number (if known) Claimant submits this order in good faith and agrees to only share disclosures with legal counsel and their insurers. ✔ Submit Form Service Price Purchase Statutory Notice Preparation & Service $195 Pay Now Additional Notices to Insurers $85 Pay Now Expedited Same Day Service $85 Pay Now
