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First Name
Last Name
Place of residence:
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Your E-mail
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So that we can get back to you
Incident information – please fill in with as much detail as possible: - What exactly happened leading up to, during and after the incident?
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If an Accident occurred, what damage, if any, was caused to the vehicle?
Location of incident (E.g street/road name/ City / town)
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What were your feelings at the time of the incident?
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Did the police get involved? If yes, please are you able to provide a crime number?
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Was the situation resolved?
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What was the footage captured on? A Dash Cam, phone, etc.
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Date of Incident
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Time (Estimate)
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I consent to using my name and town/place of residence in the media: (If you click no we will keep you anonymous
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Is there any legal action ongoing regarding your incident?
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