2023 Maui Fires Client Intake

2023 Maui Fires Client Intake

WRONGFUL DEATH INFORMATION ONLY

BODILY INJURY INFORMATION ONLY

BUSINESS PROPERTY LOSS INFORMATION ONLY

PERSONAL PROPERTY LOSS INFORMATION ONLY

REAL PROPERTY LOSS INFORMATION ONLY

ADDITIONAL COSTS INFORMATION ONLY

FLEEING THE FIRE INFORMATION ONLY

OTHER FIRE RELATED QUESTIONS

DOCUMENTS

2023 Maui Fires Client Intake

ANDREWS & THORNTON
Lead Client File Name

First NameMiddle NameLast Name
Caller's Name:

First NameMiddle NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address of Damaged Property (Resort, Damaged Home, etc.)

Facility/Resort/Hotel/Business Name

Street Address

CityState / 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

MonthDayYear
Date
Is this a wrongful death case?
Is this a bodily injury case?
Is this a personal/business property case?
Is this a real property case? Example: Home
Is this a fleeing the fire case?
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?
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 NameMiddle NameLast Name
Relationship to Caller:
Decedent's Date of Birth:

MonthDayYear
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:

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 NameMiddle NameLast Name
Did injured person seek medical treatment for injuries?
Address of Medical Facility:

Facility Name

Street Address

CityState / 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

CityState / 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?

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:

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.
Should be Empty:

Relationship to Decedent

Phone Number

Adult/Minor