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Name
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Address
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Address or Proximate Location with Street Names
Include name, address and phone number
Include name, claim number, policy number and any other information that you have.
Please state names, addresses, telephone numbers and emails of everyone that witnessed the incident.
Include agency, report number, and officer name
Please indicate the type of injury and each part of your body affected
I.E scars, deformities, aches, pains and disabilities due to the incident
If so, please provide name, address and telephone number
If so, please provide names, addresses and telephone number to all treatment providers
Describe in detail the daily impact of your injury and how it effects you
Example-have trouble sitting for more than 30 minutes at work, can’t lift child, can’t workout, can’t do work tasks, can’t play in softball league, etc.
(If so, please describe the accident, the date of the accident, injuries caused by the accident, and all medical providers that treated you for injuries).
If so, please state the facts of the lawsuit and the date of the incident.

Employment Background

Please fill out the following if you lost wages, had to use PTO or sick time as a result of the injury.

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