About GOIRA
Claimable event
PIDA
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About GOIRA
Claimable event
PIDA
Contact
QUICK CLAIM
File a claim against an individual
If you need to attach more than 5 files below, simply submit another claim.
Report
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Indicates required field
Your name (the damaged or injured party)
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First
Last
Unless you are completing this form for someone else, you are known as the plaintiff.
Would you prefer we attempt to hold your name as anonymous as possible, unless it must be revealed to complete mediation?
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No, you may use my name immediately in the claim
Yes, make me as anonymous as possible
Your email
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This claim is against the following (those liable)
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include the name(s), with email address(s), phone number(s), and website(s)
On a scale from one (1) to five (5), with 5 being the highest, what would you rate this individual/organization in terms of your overall satisfaction?
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1 star rating (lowest / least satisfaction)
2
3
4
5 star rating (highest / most satisfaction)
Where the event occurred and address (street, city, state)
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Claim summary
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organized and easy-to-understand claims are facilitated the quickets
Desired outcome
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If applicable, if there is a financial remedy which may offset the damage/injury, input it here [an amount may be able to be garnished from the liable party(s) Universe Statutory Obligations (USOs) https://www.usdibs.us ]:
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In United States Dollar (USD) $ currency please
If the liable party(s) fail to attempt to mediate via GOIRA, is there a chance you'll invoke civil action (outside of GOIRA) to seek a financial or other remedy?
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Yes
No
Maybe
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Max file size: 20MB
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Max file size: 20MB
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Max file size: 20MB
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Max file size: 20MB
If you need to attach more than 5 files, simply submit another claim
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About GOIRA
Claimable event
PIDA
Contact
