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Claiming Form

1. How bad is the injury?
<1-2 Slight Discomfort
3-5 Surgery
6-Passed Away
2. Where are the injuries?
Select all affected body parts
3. What is your name and phone number?
4. What kind of case is this?
Select the category type for the reason you're contacting us.
5. When did this happen?
6. Describe the incident
Provide as much detail as you can. (ie. people involved, police report, etc.)