gen-intake – Liberty Property Damage

Please complete the form below.

Client Intake

Date Today

First Name*

Last Name*

Your Email*

Address

City

State

Zip Code

Telephone (Work)

(Cell)

Your Car's Year*

Your Car's Make*

Your Car's Model*

Your Car's Color*

Your License Plate #

Your VIN*

Current address of your vehicle

?

City (current add)

State (current add)

Zip Code (current add)

Their Telephone

Did you filed a claim with your insurance

Your Insurance Company

Your Claim No.

Your Policy No.

Do you have collision insurance

Date of Loss

Time

Location*

?

City*

Police on scene

Do you have a police report?

Citations Issued to Def?*

If Yes, to Who and Why

Def Driver’s Name*

Defendant’s Address

Defendant’s City

Defendant’s State

Defendant’s Zip Code

Def Owner’s Name*

?

Owner’s Address

Owner’s City

Owner’s State

Owner’s Zip Code

Def's Vehicle Year*

Def's Make*

Def’s Model*

Def’s Color*

Def Insurance Co*

Def’s VIN

Def's License Plate #*

Def’s Claim No*

Def’s Policy No*