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August 2023 Flood Intake - Generic

Name(Required)

First Last

Your Spouse's, Roommate's or Partner's Name

First Last

Mailing Address(Required)

Street Address City State ZIP Code

Is your mailing address the address that flooded?(Required)

Flooded Address if Different from your Mailing Address

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Enter Email Confirm Email

Referral(Required)

Was the flooded address in Birmingham, Beverly Hills or Trenton?(Required)

Name of other referral law firm

Did your home flood on:(Required)

What was the "other date" of flooding?

How many inches of water did you have in your home?(Required)

How did the water enter the home?(Required)

Did your neighbor's flood?

Yes

Do not know

Did you file a PA222 written notice of claim with the government within 45 days of discovering the flood damage?(Required)

List the governmental entities that were served with the PA 222 NOC:

PA222 Writen Notice of Claim(Required)

By clicking this box, you informed the caller was the caller's responsibility to timely file the PA222 Notice with each responsible governmental entity within 45 days of discovering the flood damage. You informed them that Dubin Law, PLLC will NOT be filing a PA222 written notice on their behalf.

Misc Information Provided

Please include any additional fact that is relevant from your intake.

Intake Person(Required)

August 2023 Flood Intake - Generic

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Dubin Law, PLLC