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5.

State the year, make, and model of the vehicle involved, and the names of the

owners as they are registered.

Year

Make

Model

6.

State the time, date, and place of accident.

Time Date

Place

7.

Please state the weather conditions and also the specific road conditions.

8.

Did a law enforcement officer investigate the accident, if so, which municipality?

If you recall the name of the officer, please state the officer’s name.

Yes No

Officer’s name

Municipality

9.

Have you been contacted by an adjuster? If so, did you give anyone a written or

recorded statement? If so, please state when you did this and if you were supplied a copy of the statement.

Adjuster

Date of statement

Copy of statement

No copy of statement

Copy enclosed

4

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