Intake sheet
With specificity, please provide the requested information below.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
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Please upload a picture of your license for identify verification purposes.
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Can you please describe with specificity the issue you are facing?
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Can you please describe the date and time and specific facts around the issue you are facing?
Do you have any documents or photographs regarding the issue you are currently facing? If so, please attach.
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Background Information
How did you hear about us?
*
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Arag
Legal Ease
Legal Access
U.S Legal Shield
Internet
Other (Please specify...)
If you are through a referral service, what is your claim number, if any?
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Is there any additional information you would like to add? If so, please provide below.
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