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What kind of accident were you in?
Work Accident
Car Accident
Other
Where did the accident occur?
Workplace
Road
Public Area
Home
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Were you working during the accident?
Yes
No
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Did you report the injury?
Yes
No
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Do you have medical bills?
Yes
No
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Are you unable to work?
Yes
No
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Do you have any witnesses?
Yes
No
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Are you currently represented by an attorney for this claim?
Yes
No
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Was the accident your fault?
Yes
No
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Did you see a doctor or receive any medical treatment?
Yes
No
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Do you have insurance?
Yes
No
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What is your main injury?
Anxiety
Back or Neck Pain
Brain Damage
Broken Bones
Burns
Cuts and Bruises
Headaches
Hearing Loss
Loss of Limb
Memory Loss
Paralysis
Stitches
Surgery
Vision Loss
Other
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When is the best time to call you?
Morning
Afternoon
Evening
Anytime
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What is your credit rating?
Excellent
Good
Fair
Poor
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