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Where did the accident happen?

When did the accident happen?

Is your car damaged in the accident?

YES

NO

Who was hurt in the accident?

I was hurt

A loved one was hurt

We were both hurt

No one was hurt

Did the injured person receive treatment?

Treated at a hospital

Treated at a doctor's office

Was not treated

What is the primary injury?

Anxiety

Back or Neck Pain

Broken Bones

Cuts and Bruises

Headaches

Memory Loss

Loss of Limb

Other

Was a police report filed?

Yes

No

Did the police report say you are at fault?

Yes

No

What is your name?

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