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Fire Loss Contact Form

The United States has one of the highest fire injury and death rates in the industrialized world. Burn injuries are second only to motor vehicle accidents as the leading cause of accidental death in the United States. On average in the United States someone dies in a fire nearly every 2 hours, and someone is injured every 23 minutes.

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Fire Loss Contact Form

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

When was the fire and where did it take place?

Did the fire cause any property damage?
Yes  No 

Were you injured or burned in the fire?
Yes  No 

Do you know what started the fire and the names of any responsible individuals or companies?
Yes  No 

Were there any dangerous conditions where the fire started that you think started the fire or made it worse?
Yes  No 

Was anyone else injured in the fire?
Yes  No 

Do you know the names and identity of any eyewitnesses?
Yes  No 

Do you have any photographs of your injuries or any other physical evidence?
Yes  No 

What is the extent of your injuries?

Have your burns been rated and has a percentage of body affected been determined?
Yes  No 

What is your diagnosis and prognosis?

What are the costs of to-date medical treatment and the estimated future cost of treatment including reconstructive surgery?

What activities are you unable to participate in since your injury?

Have you received any benefits from anyone or been contacted by any insurance companies?
Yes  No 

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