How did you get hurt?
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Car/Truck Accident
Bike/Motorcycle Accident
Work Accident
Other Accident
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Was the accident your fault?
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Yes
No
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When did the accident happen?
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-
Month
-
Day
Year
Date
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Were you or a loved one physically hurt?
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Yes
No
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Did You See a Doctor?
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Yes
No
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Is an attorney helping you with your claim?
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Yes
No
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Name
*
Phone
*
Email
*
Summary
*
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