DAR-LIENS : Arizona’s Premier Lien Service

INFORMATION REQUIRED TO GET A POLICE REPORT ON YOUR PERSONAL INJURY CASE

This form is also available as a PDF document to print and mail to our office or to fax to 602.942.0763. Download this form.


Doctor & Clinic Name
Patient Name
Other Driver's Name
Your E-mail
Date of Accident
Time of Day Accident Happened
Accident Location
City
State	Zip
Investigating Police Department
By submitting this document you have authorized Dar-Liens, Inc. to obtain a police report on your behalf. There is a $20.00 charge per report. You will receive a copy of the accident report in the mail for your patient file. If there has not been a police report filed, there will be a $10.00 service fee billed to your account.