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How were you hurt?
Automobile Accident
Accident or Injury at Work
Medical Negligence
Fall or Slip
Other Injury or Accident
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Who else was involved in the accident?
Another driver (other car involved)
No one else, I hit a deer/tree/swerved off the road
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Did you have to go to the doctor?
Yes
No
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Are you currently represented by an attorney?
Yes
No
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Were you at fault?
Yes
No
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When did this accident happen?
Within 1 Week
Within 1-3 months
Within 1 Year
Longer than 1 Year
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Describe Your Incident.
Last Name
First Name
Email
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Phone
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