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ACCIDENT INFORMATION REPORT

INSTRUCTIONS: TO MAXIMIZE YOUR POTENTIAL RECOVERY, ONCE SAFE TO DO SO, COMPLETE AS MUCH INFORMATION AS POSSIBLE AT THE SCENE OF THE ACCIDENT. IF UNABLE, COMPLETE THE REMAINDER AS SOON AS POSSIBLE.

YOUR INFORMATION:

YOUR VEHICLE:

OTHER VEHICLES:

INJURIES SUSTAINED:

INJURIES SUSTAINED : NAMES / ADDRESS / CONTACT OF WITNESSES

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