Pacific Palisades Fire Litigation

Section A: Case Information

Original Case Name *

Original Case Number *

Law Firm (if represented)

Plaintiff Information

Plaintiff 1

Plaintiff Type *

Individual

Business

Trust

Estate

Plaintiff Name or Entity Name *

Individual Plaintiff Date of Birth

Is this plaintiff a minor, deceased, or incapacitated?

Yes

No

Status

Name of Representative

Relationship to Plaintiff

Capacity of Representation

If court-appointed, provide:

Bankruptcy Information

Has any plaintiff been a debtor in bankruptcy proceedings on or after the Pacific Palisades Fire?

Yes

No

Plaintiff Name

Bankruptcy Case Number

Section B: Affected Properties

List all properties that were affected by the Pacific Palisades Fire

Property 1

Street Address *

City *

ZIP Code *

Assessor Parcel Number (APN)

Is this property insured?

Yes

No

Insurance Carrier

Policy Number

Claim Number

Property Damage Details

Was there a dwelling at this location that was damaged?

Was there a commercial structure at this location that was damaged?

Were there other structures at this location that were damaged?

Did the real property sustain a diminution in value? (Owners Only)

Yes

No

N/A - Not Owner

Was personal property damaged at this location?

Did you experience loss of use of this property?

Yes

No

Section C: Individual Damages

Did you evacuate or shelter-in-place as a result of the Pacific Palisades Fire? *

Evacuate

Shelter-in-Place

Neither

Evacuation or Shelter-in-Place Address

Did you suffer emotional distress as a result?

Yes

No

Did you suffer physical bodily injury as a result of the fire?

Yes

No

General nature of the injury

Were you hospitalized?

Yes

No

Did you suffer loss of personal income as a result of the fire?

Yes

No

Cause of income loss

Property damage/destruction

Physical injury

Applicable loss location(s)

Section D: Business Damages

Did you suffer loss of business profits as a result of the fire?

Yes

No

Business Name

Business Address

Applicable loss location(s)

Section E: Vehicle Damages

Were any vehicles damaged or destroyed by the fire?

Yes

No

Vehicle 1

Title Owner(s)

Make

Model

Year

VIN

Damage Status

Insured?

Yes

No

Section F: Wrongful Death

Are you asserting a claim for wrongful death or survival as a result of the Pacific Palisades Fire?

Yes

No

Name of Decedent

Date of Death

Place of Death

List all known heirs

Your relationship to decedent

Declaration and Signature

Declaration Under Penalty of Perjury

I hereby declare under penalty of perjury under the laws of the State of California that I have read the foregoing Plaintiff Fact Sheet and know its contents. The same is true of my own personal knowledge except for those matters stated on information and belief which I believe to be true.

Printed Name *

Date *

Email for Confirmation *

I understand that by submitting this form, I am signing it electronically and that my electronic signature is the legal equivalent of my manual signature on this Plaintiff Fact Sheet *

Important Instructions