Please enter the contact details of the person making the insurance claim.
Name
City
Province
Phone
Email
Type of Claim Motor Vehicle Accident (including Pedestrian)Short- and Long-Term DisabilitySlip and FallFire and HouseOther
If "other", please specify:
Date of Loss (if applicable)
Time of day of the accident
Motor Vehicle Accident DriverPassengerPedestrian
Location of accident
Briefly describe the accident
Names of passengers and relationship to driver (if applicable)
Name of driver (if a different person than the one making this insurance claim)
Please describe injuries resulting from this accident
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.
Referring Law Firm
Referring Lawyer Name
Date
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