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8383 Wilshire Blvd.
Suite 336
Beverly Hills, California 90211
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Toll Free: 1.800.252.9776

Contact Information: Name:* Address: City: State: ZIP: Phone Number:* Email:*

Matter Information: Were you injured? Were other people injured? Did a relative die? If a relative died, state how you were related. What is the nature or extent of your injuries? Are the injuries permanent? Where did the accident or injuries occur? How did the accident or injuries occur? Do you have the name and address of the person who caused the accident? State the names and addresses of the person or persons who caused the accident. How much are the medical bills? How much is the loss of earnings to date? Does the other party (wrongdoer) have liability insurance? If you were in an automobile or motorcycle accident and you were the driver, did you have liability insurance? Do you have medical insurance? If this was an automobile or motorcycle accident, was there a police report? Were there any witnesses? State the names and addresses of the witnesses. Have you filed a lawsuit? Telephone number and a convenient time to call you. Please indicate any other facts that you believe are important.

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