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This guide provides clear and supportive instructions on how to complete the information regarding a possible claim against a third party form, specifically for veterans. Follow this step-by-step guide to ensure that your form is filled out correctly and submitted efficiently.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin filling out the veteran's name, entering their last name, first name, and middle initial in the designated fields.
3. Provide the veteran's telephone number in the appropriate space, ensuring it is correct for contact purposes.
4. Fill in the complete address of the veteran, including number, street, city, state, and zip code.
5. Enter the veteran's social security number in the designated area. Ensure this is accurate, as it is sensitive information.
6. Input the date of the report in the specified format. This is important for record-keeping.
7. If someone other than the veteran is providing information, include their name, telephone number, and address.
8. Describe the nature of the injury or disease in the allocated section. Be as specific and clear as possible.
9. Fill in details of any reimbursable insurance, including the insurance company name, address, policy number, and whether the coverage is group or individual.
10. If the claim is against a third party, provide the name and address of that party.
11. Indicate whether the veteran has submitted a claim orally or in writing by selecting the appropriate option.
12. If a claim has been submitted, note to whom and when it was submitted.
13. List the names, telephone numbers, and addresses of any witnesses relevant to the incident.
14. Provide detailed information including the date, time, exact location, and a description of the incident that resulted in the injury.
15. Mention any authorities that conducted an investigation related to the incident.
16. Indicate whether the veteran has contacted an attorney by selecting yes or no.
17. Complete the remarks section with any additional information that may be pertinent.
18. If applicable, fill in the name and address of the attorney representing the veteran.
19. Once all fields are filled out accurately, save the changes, then download, print, or share the completed form as needed.

Complete your forms online today to ensure your claims process starts smoothly.