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please complete the form below as accurately as possible.
Who / What is the other party?
Current status of loss / injury:
Have you lost any income as a result of the loss
Have you been contacted by an insurance adjuster?
Have you provided any written statements to anyone?
Do you have any photographs of your loss / injuries?
Have you ever filed an insurance claim before?
Have you ever been a party to a lawsuit before?
Other questions / comments: