{"id":6244,"date":"2024-05-04T13:33:17","date_gmt":"2024-05-04T16:33:17","guid":{"rendered":"https:\/\/dev.corazzamarketing.ca\/fidelis2\/?page_id=6244"},"modified":"2024-05-04T13:53:42","modified_gmt":"2024-05-04T16:53:42","slug":"insurance-claim-referral","status":"publish","type":"page","link":"https:\/\/fidelislaw.ca\/dev\/insurance-claim-referral\/","title":{"rendered":"Insurance Claim Referral"},"content":{"rendered":"<div class=\"gb-container gb-container-844d87ad\">\n<div class=\"gb-container gb-container-748be95d\">\n\n<div class=\"wp-block-contact-form-7-contact-form-selector\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f6243-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"6243\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/dev\/wp-json\/wp\/v2\/pages\/6244#wpcf7-f6243-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"6243\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f6243-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<h2>Personal Information\n<\/h2>\n<p>Please enter the contact details of the person making the insurance claim.\n<\/p>\n<p><label> Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Name\" \/><\/span> <\/label>\n<\/p>\n<p><label> City<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"City\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"City\" \/><\/span> <\/label>\n<\/p>\n<p><label> Province<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Province\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Province\" \/><\/span> <\/label>\n<\/p>\n<p><label> Phone<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"Phone\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n<\/p>\n<h2>Accident Details (if applicable)\n<\/h2>\n<p><label> Type of Claim <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"TypeOfClaim\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"TypeOfClaim\" value=\"Motor Vehicle Accident (including Pedestrian)\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Motor Vehicle Accident (including Pedestrian)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"TypeOfClaim\" value=\"Short- and Long-Term Disability\" \/><span class=\"wpcf7-list-item-label\">Short- and Long-Term Disability<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"TypeOfClaim\" value=\"Slip and Fall\" \/><span class=\"wpcf7-list-item-label\">Slip and Fall<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"TypeOfClaim\" value=\"Fire and House\" \/><span class=\"wpcf7-list-item-label\">Fire and House<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"TypeOfClaim\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> If \"other\", please specify:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"OtherTypeOfClaim\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"OtherTypeOfClaim\" \/><\/span> <\/label>\n<\/p>\n<p><label> Date of Loss (if applicable)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateOfLoss\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"DateOfLoss\" \/><\/span> <\/label>\n<\/p>\n<p><label> Time of day of the accident<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"TimeOfDay\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"TimeOfDay\" \/><\/span> <\/label>\n<\/p>\n<p><label> Motor Vehicle Accident <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"MVA\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"MVA\" value=\"Driver\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Driver<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"MVA\" value=\"Passenger\" \/><span class=\"wpcf7-list-item-label\">Passenger<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"MVA\" value=\"Pedestrian\" \/><span class=\"wpcf7-list-item-label\">Pedestrian<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Location of accident<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"AccidentLocation\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"AccidentLocation\" \/><\/span> <\/label>\n<\/p>\n<p><label> Briefly describe the accident<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"AccidentDescription\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"AccidentDescription\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><label> Names of passengers and relationship to driver (if applicable)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Passengers\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Passengers\" \/><\/span> <\/label>\n<\/p>\n<p><label> Name of driver (if a different person than the one making this insurance claim)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Driver\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Driver\" \/><\/span> <\/label>\n<\/p>\n<p><label> Please describe injuries resulting from this accident<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Injuries\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"Injuries\"><\/textarea><\/span> <\/label>\n<\/p>\n<h2>File Management\n<\/h2>\n<p>We agree to transfer this matter to Fidelis Law Droit in exchange of the previously agreed upon fees billed in this matter, which shall be payable upon resolution, including by settlement, mediation, or judgment.\n<\/p>\n<p><label> Referring Law Firm<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ReferringFirmName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ReferringFirmName\" \/><\/span> <\/label>\n<\/p>\n<p><label> Referring Lawyer Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ReferringLawyerName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ReferringLawyerName\" \/><\/span> <\/label>\n<\/p>\n<p><label> Date<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateOfAgreement\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"DateOfAgreement\" \/><\/span> <\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"236\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\n<\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-6244","page","type-page","status-publish"],"acf":[],"_links":{"self":[{"href":"https:\/\/fidelislaw.ca\/dev\/wp-json\/wp\/v2\/pages\/6244","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/fidelislaw.ca\/dev\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/fidelislaw.ca\/dev\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/fidelislaw.ca\/dev\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/fidelislaw.ca\/dev\/wp-json\/wp\/v2\/comments?post=6244"}],"version-history":[{"count":2,"href":"https:\/\/fidelislaw.ca\/dev\/wp-json\/wp\/v2\/pages\/6244\/revisions"}],"predecessor-version":[{"id":6260,"href":"https:\/\/fidelislaw.ca\/dev\/wp-json\/wp\/v2\/pages\/6244\/revisions\/6260"}],"wp:attachment":[{"href":"https:\/\/fidelislaw.ca\/dev\/wp-json\/wp\/v2\/media?parent=6244"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}