Personal Information

Please enter the contact details of the person making the insurance claim.

Name

City

Province

Phone

Email

Accident Details (if applicable)

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

File Management

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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