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As 75007 Phone: (972) 512-5600 Fax: (972) 512-5820 Toll Free (866) 523-3452 Policy Number: PART I POLICYHOLDER S REPORT 1. Claimant s Name (Injured Person) 2. Social Security Number 3. Gender M F 4. Date of Birth 5. E-Mail 6. Address of Injured Person and Best Contact Phone Number (Include Area Code) 7. If Applicable, Parent s Name, Address, and Best Contact Phone Number (Include Area Code) 8. Date and Time of Accident Dental Claims 9. Place where Accident Occurred 11. Indi.

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