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Contact Information

First Name

Last Name

Phone Number

Do you know the name of the fire that impacted you?

Did you suffer harm to your Home, Business, or other personal property?

Residential Loss

Business Loss

Personal Property Loss

Were you forced to evacuate?

What is your date of birth? Please use the calendar to select your date of birth.

Loss Address

What was the address where you or your family suffered losses or harm related to the fire? (e.g., your home or business address)?

Street Address

City

State

Zip Code

What was your relationship to the property?

Did you live at this property?

Did you live with someone who rented or owned the property?

Damage Level

Is there anything else we should know?

Comments

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Please have your parent or guardian visit https://edelson.com/Eaton-Fire to become a client.