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Full name
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Phone number
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Email
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What state did the accident happen in?
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A
New York
B
Texas
C
California
D
Another state
County or city where it happened
Date of the accident
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What type of accident was it?
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A
Motor vehicle / car / rideshare
B
Construction site / scaffold / fall
C
Slip-and-fall / sidewalk / building
D
Commercial truck / 18-wheeler
E
Pedestrian struck
F
Other / not sure
Did you receive medical care?
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A
Yes
B
No
C
Not sure
Were emergency services (police or ambulance) called?
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A
Yes
B
No
C
Not sure
Briefly describe what happened
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