When you have completed the form, simply click on the SEND button at the bottom. Simpson Thomas will be in touch soon. Your Contact Information Name: * Address: * City: Province: Postal Code: Email: Telephone: *   Please indicate if this is: your home, cell or work number Language required: ICBC Claim Information Date of Accident: Day* Month* Year* ICBC Claim Number: (if you have one) Name of ICBC Adjustor: Adjustor's Telephone No.: Claim Centre Location: The Accident Indicate if you were the: Driver Passenger Pedestrian Cyclist Location of motor vehicle accident: Description of collision: Were you injured in this accident? Yes No If yes, please briefly describe your injuries: If you were the driver, please indicate if there were any passengers in the vehicle? Yes No If yes, how many passengers? If yes, were they injured? Yes No Damage done to your vehicle (dollar amount): $ Warning Generally, you have 2 years from the date of the accident to start a lawsuit (the "Limitation Period") or all of your rights become extinguished. Further, if you have to claim against a municipality, then your Limitation Period is much shorter (you have 60 days to notify the municipality/district/city). I have read and understood this warning: * Yes   * These fields are mandatory By filling out this form you are simply arranging an interview with a lawyer and not protecting any of your rights. It is important for you to know that by filling out this form you are NOT retaining Simpson Thomas to act for you and Simpson Thomas will not take any steps to protect your rights until you have met with one of our lawyers.

Please contact Simpson Thomas immediately at 604.689.8888 or email info@simpsonthomas.com.