Long Form Complete Client Signup Packet

Wearing Seatbelt Yes No

Texting While Driving Yes No

Defendant Texting While Driving Yes No

Are you a Uber, Lyft or Commercial Driver Yes No

If You Drive Uber or Lyft, Did You Tell Your Insurance Yes No

Rate the Damage Minor Moderate Severe

Is The Vehicle Drivable Yes No

Did You Go To The Hospital? Yes No

ER Only Not Admitted Yes No

Ambulance Yes No

Fire Rescue or Emergency Services Yes No

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business. Yes No