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Name
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Phone
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Email
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When did the claim happen?
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MM slash DD slash YYYY
What Type of Claim?
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Auto
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Please describe what happened:
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Was anyone injured?
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Yes
No
Who was injured?
Which vehicle was involved?
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Who was the driver?
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Is the car still drivable?
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Were the police called?
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Yes
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What is the police report number?
Were any other cars involved?
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Yes
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What is the other driver's information?
What address is the damage at?
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Has anyone been called to help address the damage?
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Yes
No
Who has been called?
Anything else we need to know?
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