2023 Maui Fires Client Intake
ANDREWS & THORNTON
Lead Client File Name
First Name
Middle Name
Last Name
Caller's Name:
First Name
Middle Name
Last Name
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address of Damaged Property (Resort, Damaged Home, etc.)
Facility/Resort/Hotel/Business Name
Street Address
City
State / Province
Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number (Do Not Include Cell Number Here)
Please enter a valid phone number.
Format: (000) 000-0000.
Business/Other Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Is this a wrongful death case?
YES
NO
Is this a bodily injury case?
YES
NO
Is this a personal/business property case?
YES
NO
Is this a real property case? Example: Home
YES
NO
Is this a fleeing the fire case?
YES
NO
If none of above, is this an other injury case? If so, describe injury:
Were you a visitor or resident of Maui at the time of fire?
Resident
Visitor
OTHER
If other, please explain:
Purpose of Trip:
Resident Family History (describe family history on the island, how long caller has lived on island, what led them to the islands, do you feel comfortable describing your ethnicity (i.e. - 5th generation Japanese/Hawaiian bloodline)
WRONGFUL DEATH INFORMATION ONLY
Full Legal Name of Decedent:
First Name
Middle Name
Last Name
Relationship to Caller:
Decedent's Date of Birth:
-
Month
-
Day
Year
Date
How long did decedent live in Hawaii?
Resident Family History (describe family history on the island, how long decedent lived on island, what led them to the islands, do you feel comfortable describing your ethnicity (i.e. - 5th generation Japanese/Hawaiian bloodline)
Describe the decedent: (Height, weight, relationship status (married, etc.), children, hobbies, interests, occupation, education)
Facts Surrounding Decedent's Death (where, when, how, manner of death):
How and when did the caller learn about the fire?
Did you investigate the decedent's whereabouts before learning of his/her passing? If so, explain:
How were you informed of decedent's passing?
Have arrangements been made for decedent's remains/estate? If so, please explain:
Provide information about any surviving heirs:
Rows
Full Name
Relationship to Decedent
Address
Phone Number
Email
Adult/Minor
Heir 1
Heir 2
Heir 3
Heir 4
Heir 5
If there are more than 5 heirs, provide information above for any additional heirs:
Has any family member sought legal representation? If so, state heir's name, name and law firm.
Are there family issues we should be aware of?
BODILY INJURY INFORMATION ONLY
Full name of Injured Person:
First Name
Middle Name
Last Name
Did injured person seek medical treatment for injuries?
YES
NO
Address of Medical Facility:
Facility Name
Street Address
City
State / Province
Postal / Zip Code
Description of Injury:
Description of how injury occurred:
Description of ongoing care (if applicable):
Name of Health Insurance:
Health Insurance Policy Number:
BUSINESS PROPERTY LOSS INFORMATION ONLY
Address of Business:
Name of Business
Street Address
City
State / Province
Postal / Zip Code
Type of Business (Describe):
List of lost business property (item description, approximate value or any other pertinent information):
Identify property that may be insured. Include insurance company, policy number and if a claim was filed and status.
PERSONAL PROPERTY LOSS INFORMATION ONLY
List of lost personal property (item description, approximate value or any other pertinent information):
Identify personal property that may be insured. Include insurance company, policy number and if a claim was filed and status.
REAL PROPERTY LOSS INFORMATION ONLY
Describe extent of real property damage (total loss, partial loss, minor/major structural damage, etc.)
Name of Insurance Company (if any)
Policy Number
Full name of insurance policy holder, if not by you:
Did you rent or own the damaged property?
Rent
Own
Other
If other, please describe:
If renting, provide full name and phone number of landlord:
Identify if insurance company was contacted. Describe if a claim was filed and provide claim status.
ADDITIONAL COSTS INFORMATION ONLY
New incurred costs and non-refunded costs:
Flight Costs (new flights, non-refunded flights)
Hotel Costs (new hotel reservations, non-refunded hotel reservations)
Rental Costs (new rentals, non-refunded rentals)
Other Costs (new additional costs, non-refunded items/excursions/reservations)
FLEEING THE FIRE INFORMATION ONLY
Identify any else that was fleeing the fire with the caller? Provide as much information as possible:
Rows
Full Name
Relationship to caller
Address
Phone Number
Email
Adult/Minor
Person 1
Person
2
Person
3
Person
4
Person
5
Where were you in the morning/afternoon before the fire struck?
When and how did you first notice the fire?
When and how did you evacuate (make sure to get details of proximity to fire, escape route including street names, obstacles, were you trapped)
OTHER FIRE RELATED QUESTIONS
Where did you stay after the fire? Describe in detail:
Describe any other affected parties (person's names, contact info, relationship, how do they link to your case)
Do you know of any other missing persons? Names, Relationship, Contact Info of Friends/Family that know them:
DOCUMENTS
Does caller have photos? If so, describe:
Does caller have texts/emails? If so, describe:
Does caller have insurance documents? If so, describe:
Does caller have any other documents? If so, describe:
Please provide any additional details you would like concerning your potential claim here.
Submit
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