Brief description of your
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Are you represented by an attorney?
I was represented by an attorney in the past but not anymore
At the time of the accident, were you the?
Occupant or Passenger
Were you at fault?
What type of accident were you involved in?
With another vehicle
With a commercial truck
With an 18 wheeler
Are you currently represented by an attorney?
Are you a Medicare or Medicaid recipient?
Did you seek treatment at any medical providers for you injuries?
What injuries did you suffer due to your accident?
Date of Accident:
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Did you miss work due to accident?
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Before and After
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Are you a homeowner
Is it a single family home
Average monthly energy bill cost $
Tree coverage over roof
I'm not sure
600 - 650
650 - 700
I'm not sure
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