| First and Last Name: |
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| Street Address: |
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| City: |
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| State: |
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| Zip Code: |
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| E-mail: |
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| Phone: |
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| Details of Accident: |
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| City & State Where Accident Occurred: |
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| Date & Time of Accident: |
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| Describe Your Injuries: |
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| Model & Year of other vehicle which caused the injuries (if known): |
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Citations
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| Was the other person cited with a traffic violation? |
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| Were you cited with a traffic violation? |
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Insurance Coverage
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| Did the other person causing the accident have insurance? |
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| If YES, name of insurance company: |
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| Do you have Uninsured/Underinsured insurance? |
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| If YES, name and insurance company and amount of insurance if known: |
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| Your Status in Accident: |
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| How did the other person cause your accident? |
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| Other cause: |
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| Did the other person leave the scene of the accident? |
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| Are there witnesses to the accident other than you? |
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| How did you hear about us?
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