USAC_Intake_3 – USAccidentClaim.com

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Name*
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Were you at fault for the accident?*
Do you have a lawyer representing you?*
Were you hospitalized or did you receive medical treatment for your injury?*
How long ago did this accident happen?*
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Email*

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Other Details
Type of Injury (Please Select Any or All that Apply)*
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- Back or Neck Pain
- Head Injury or Head Aches
- Cuts or Bruises
- Broken Bones
- Shoulder, Knee, or other Joint Pain
- Depression, Anxiety or Post Traumatic Stress Disorder
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