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13.

Were you hospitalized? If so, where and for how long?

Yes

No

Hospital

Period of time

14.

Please state where you are employed and whether you have lost income as a

result of this accident. If you have lost income, please state the amount, and the

date(s) you lost work.

Place of employment:

Address:

Job Title:

Hourly wage or salary:

Amount of income lost:

Dates of work lost:

Do you anticipate further loss of wages?

Yes

No

15.

What is your marital status, yearly income, number of dependents, educational

background, job (career potential) and age?

Age

  • #

    of dependents

Marital status

Yearly income

Job information

Education background

16.

Do you have any insurance policies (automobile, health, accident, disability,

etc)? Please provide us with copies of ALL of your policies.

Automobile

Insurance Company

Address and telephone

Policy #

Please provide a copy of the policy.

6

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