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17.

Were there any witnesses to the accident? If so, please list their names and

addresses (if known). Please state if you know the witness, aside from this accident.

Name

Address

Phone #

Name

Address

Phone #

Name

Address

Phone #

18.

Were there other injuries in the same accident? If so, how many people were

hurt and who were they?

Yes No

How many

Names:

19.

Please state the name of the contact person with your employer to verify time

loss from work resulting from this accident, and in order to obtain a statement as to your

hourly, weekly, or average wage.

Name:

Phone #

Title or position

8

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