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What type of injuries do you have? Auto/Motor Vehicle Accident Slip and Fall Dog Bite & Animal Attack Sexual Assualt Wrongful Death Hurt on the Job Other
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Have you filed any claims? Yes No
Have you filed a police report? Yes No
Were there any witnesses? Yes No
Do you have insurance that covers you for this type of incident? Yes No Not Sure
Do other involved parties have insurance that covers this type of incident? Yes No Not sure
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