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Date of Birth State City Daytime Phone ( Evening Phone ( ) ) Property Damage Cell/Pager ( ) CA Driver s License # Soc. Security # or Bus. Tax Id. # Type of Loss: Personal Injury Zip Other Police Report # Indemnity - Date complaint served When did injury or damage occur? (Month/Day/Year) (Day of Week) Where did injury or damage occur? (Street address, intersecting streets, or other location) AM /PM (Time) How did injury or damage occur? (Describe accident or.

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