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How were you injured?

When were you injured?

What is the extent of your injuries?

Have you seen a doctor?

Yes
No

How much are your medical bills?

Have you filed any claims?

Yes
No

Did the police respond?

Yes
No

Did anyone receive a ticket?

Yes
No

If yes, what for?

Was anyone arrested?

Yes
No

If yes, what for?

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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