Contact Infomation ^*

First Name ^*

Last Name ^*

Email ^*

Phone Number ^*

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Address ^*

City ^*

State ^*

Zip ^*

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Do You Own or Rent Your Home? ^*

I own my home

I rent my home

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Description of Damage (select one) ^*

Total loss

Smoke damage

Partial structural damage

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Do You Have Minors Living with You? ^*

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No

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Do You Currently Have Homeowners/Renters Insurance? ^*

Yes

No

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Insurance Provider

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Please Upload a Photo of the Damage (optional)

Photos could be helpful to attorneys to assess your claim. Do not worry if you have not been able to visit your home yet.

You can drag & drop or paste as well

Maximum file size: 10MB

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Palisades Fire Recovery Intake

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