The Wagner Law Group

DIXIE FIRE INTAKE


Client Information

Name: Date:
 
Phone: Email:  
 
DOB:  

 


Impacted Address

Address: City:
 
State: Zipcode:  

 

 

Current Mailing Address

Address: City:
 
State: Zipcode:  

 

At the time of the fire you were:

 

Nature of Loss/Damage:

 

Insurance Coverage?

 

Insurance provider:  

I acknowledge and understand that The Wagner Law Group are not my attorney and have not undertaken my legal representation until The Wagner Law Group acknowledge that they are my attorneys in writing. I further understand that this form is not legally binding.

 

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Signature Certificate
Document name: DIXIE FIRE INTAKE
lock iconUnique Document ID: 912cf77b801c1e875af1126f57495dcca0860d18
Timestamp Audit
August 23, 2021 3:14 pm PSTDIXIE FIRE INTAKE Uploaded by Rhonda Beckham - rbeckham@wagnerjones.com IP 104.174.140.255
August 23, 2021 3:44 pm PST Document owner info@wagnerjones.com has handed over this document to rbeckham@wagnerjones.com 2021-08-23 15:44:30 - 76.227.233.246
August 23, 2021 5:04 pm PSTRhonda Beckham - rbeckham@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 98.41.118.124
August 23, 2021 5:04 pm PSTSteve Amaro - samaro@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 98.41.118.124
August 23, 2021 5:04 pm PSTJake Benjamin - jbenjamin@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 98.41.118.124
August 23, 2021 5:04 pm PSTButch Wagner - bwagner@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 98.41.118.124
August 23, 2021 5:04 pm PSTAaron Benjamin - abenjamin@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 98.41.118.124
January 27, 2022 3:55 pm PSTRhonda Beckham - rbeckham@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 71.195.187.98
January 27, 2022 3:55 pm PSTJody Jones - jody@thewagnerlawgroup.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 71.195.187.98
January 27, 2022 3:55 pm PSTJake Benjamin - jbenjamin@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 71.195.187.98
January 27, 2022 3:55 pm PSTButch Wagner - bwagner@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 71.195.187.98
January 27, 2022 3:55 pm PSTAaron Benjamin - abenjamin@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 71.195.187.98
May 16, 2023 11:04 am PSTRhonda Beckham - rbeckham@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 104.174.140.255
May 16, 2023 11:04 am PSTSydney Firstman - sydney@thewagnerlawgroup.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 104.174.140.255
May 16, 2023 11:04 am PSTJake Benjamin - jbenjamin@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 104.174.140.255
May 16, 2023 11:04 am PSTButch Wagner - bwagner@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 104.174.140.255
May 16, 2023 11:04 am PSTAaron Benjamin - abenjamin@wagnerjones.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 104.174.140.255
May 16, 2023 11:04 am PSTLiz TWLG - liz@thewagnerlawgroup.com added by Rhonda Beckham - rbeckham@wagnerjones.com as a CC'd Recipient Ip: 104.174.140.255
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