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Etc., pertinent to the incident. PLEASE TYPE OR PRINT. Claimant Information Name Phone ( Address City ) Work Phone ( State ) Zip Description of Incident Time, Date and Location: Explain problem or describe what occurred: (Attach separate sheet if necessary) Describe Damage: (Property, Vehicle, etc.) Personal Injuries: Yes No If Yes, explain: If a motor vehicle was damaged, complete the following: Vehicle: Year Make Model No. License Number Body Type: 2 Door State 4 Door Seda.

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