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*Name:
*Address:
*City:
*State:
*Zip Code:
*Contact Phone Number:
Contact Fax:
*E-mail Address:
Date of Incident:
Type of Accident:
How did Injury Happen:
Make, Model Year & Color of your Vehicle
Your Insurance Company
Insurance Company Phone Number
Policy Number
Describe The Injuries:
Name of Defendant
Defendant's Address
Defendant's Phone Number
Defendant's Vehicle Make & Model
Def. Vehicle Color & year
Def. Vehicle Plate Number
Defendant's Insurance Company
Def. Insurance Phone Number
Def. Insurance Policy Number
Any Other Comments:

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291 S. La Cienega Blvd,
Suite 214
Beverly Hills, CA 90211
Phone (310)659-7171
Fax (310)659-7799


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