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Select the type of accident.*
  • - select accident type -
  • Rideshare (Uber, Lyft, etc.)
  • Car
  • Pedestrian
  • Bicycle
  • Motorcycle
  • Commercial Truck
  • E-Bike or E-Scooter
  • Other
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Select the date of your injury.*
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Where in California did the incident occur?
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Select the type of treatment received?
  • - select type -
  • Hospitalized
  • Emergency Room / Urgent Care
  • Saw Doctor or Specialist
  • No treatment was received
  • N/A Incident resulted in death
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What is the status of your medical treatment:
  • - select status -
  • I need to start treating
  • I’m treating
  • I’m done treating
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Please describe the specific facts of how the accident occurred and details of your injuries that will help us determine if you qualify for compensation.
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Please upload any relevant documents.
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