Larson Law

             (801) 601-8323

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In order to better understand your case we would like to gather some more information.  Please complete the form below and Larson Law will review the information and contact you within 72 hours. Please note, This is this is a CONFIDENTIAL and ENCRYPTED questionnaire for the use of this office only in preparing your claim for personal injuries. Please answer every question fully, honestly, and accurately because, as your attorneys, the more we know about you and your case, the better we will be able to represent you. There are 13 sections, and each of the questions are important even though they may not appear to have anything to do with your case.

Medical Providers

Please provide the following information for each and every medical provider who has treated you since the accident. This information is very important. Failure to provide information may cause medical expenses to be incorrect for which you may be liable.

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Your Vehicle Information

Other Insurance Information

Accident Information

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I have read and completed the above information and state that it is true and correct to the best of my knowledge:

Defendant's Auto Insurance Information

(Defendant is the driver who caused the accident)

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Your Auto Insurance Information

Statements Made

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Defendant's Vehicle Information



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Police Record

Personal Information

Wage Loss