Weather Records Request Form

*Today's Date:

*Your Name:

*Address 1:

Address 2:

*City:

*State:

*Zip:

Phone:

Fax:

*E-Mail:

Your Company:

Your Title:

Case Information

Case Name:

File Number:

Date of Incident:

Location of Incident:

Time of Incident:

Describe the incident: (slip & fall, vehicle, property damage, etc.)

What do you need to show or prove, specifically?:

Who do you represent?    Plaintiff    Defendant    Insured    Other (specify below)

If Other, specify:   

Date you need this information by:

Comments: