Celebrity VisaInvestor VisaFamily/Spouse/Fiancé VisaStudent VisaTourist/Visitor VisaAdjustment of StatusNaturalizationEmployment Authorization CardWork Visa⁮Travel DocumentOther: please specify

1. Did the accident occur in California?
YesNo
2. How long ago was your accident?
Less than two years agoMore than two years ago
3. Were you at fault in the accident?
No, it was not my faultYes, it was my fault
4. Did the police arrive?
YesNo
5. Are you currently represented by an attorney for this case/accident?
YesNo
6. Qualifier: “Does the other driver have auto insurance?
YesNo
7. Do you have insurance coverage?
YesNo
8. Did you visit a doctor, hospital, chiropractor or any other medical professional as a result of the accident?
YesNo
Please describe your accident

Describe your case

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