(503) 280-0888 [email protected]

  • CAR ACCIDENT INTAKE FORM
    (If you do not have some of the information we ask for, we will track it down for you.)

  • PERSONAL INFORMATION

  • Date Format: MM slash DD slash YYYY
  • ACCIDENT FACTS

  • Date Format: MM slash DD slash YYYY
  • :
  • DESCRIBE THE ACCIDENT

  • (ex: exact location, situation, Cops, Hospital/Ambulance)
  • PROPERTY DAMAGE

  • Other Driver's Car
  • INSURANCE INFORMATION:

  • Your Insurance Company:
  • Other Driver's Insurance Company:
  • INJURIES:

  • MEDICAL TREATMENT PROVIDERS:

  • (Name/Address/Phone)
  • EMPLOYMENT AND INCOME INFORMATION

  • PRIOR AUTO ACCIDENTS AND INJURIES

  • LIST ACHIEVEMENTS IN YOUR LIFE OR ACCOMPLISHMENTS

You must complete the form on the next page too, in order for Peterson Law Offices to legally represent you.

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719 NE Roberts Ave. Gresham, OR 97030 - 503-280-0888
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