Face To Face Order Information:    

     * required fields

Claim Number:    *   Loss Date: * Insured:*

Your Name:        *   Your Phone:   

Your  e-mail:                Company:       

 Mailing Address   

Please fax police report and medical authorization to : 512-535-2347

Injured Party: Parent (if minor):

Contact Phone Number:

Will obtain signed authorization, profile of claimant and injury and explanation of expectations*

Special instructions (photos, explanations other than noted below, etc.): 

*  Will explain that company adjuster will discuss settlement with them when they are ready.

 Settlements normally include consideration of reasonable and necessary medical charges,

 reasonable wage loss and a general damages amount for pain, suffering, inconvenience etc.

 In some circumstances adjuster may be able to project some medical charges and wages to be

 incurred.