Questionnaire

Lemon Law Questionnaire | Personal Injury Questionnaire

Questionnaire for Lemon Law Cases

Contact Details
Name		Name is required.
Address
Home Phone		Home Phone is required.Invalid format.
Cell Phone		Invalid format.
Work Phone		Invalid format.
Vehicle Details
Year
Make
Model
Date Vehicle Purchased
Miles on Vehicle
When Purchased
At First Major Problem
Current
Repair Details
Approximate total number of days vehicle has been in for repairs:
List the major problems with vehicle which required repairs, and how many times the problem(s) has been repaired, or attempts have been made to repair:
Problem:		Times Repaired:
Problem:		Times Repaired:
Problem:		Times Repaired:
Problem:		Times Repaired:
If the vehicle is continuing to have problems, please state the problems:
When is the best time to reach you ?
Image Verification Please enter the text from the image [ Refresh Image ] [ What's This? ]
*Please check all fields for accuracy and click submit

Phone: (661) 222-9929
Phone: (818) 904-6800
FAX: (661) 284-1811