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Claim Form:
Please complete the claim form ensuring that you provide all your details so as to assist our experts in making a quick decision for you.
Fields marked with
*
are mandatory.
Full Name
*
Address
*
Type of Accident:
*
Road traffic accident
Passenger in a vehicle
Accident at work
Accidents In Shops
Accidents in Public
Faulty Goods
Accidents in the Home
Sporting Injuries
Trip or fall
Clinical Negligience
Other
Brief Description
*
Email
*
Telephone
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Using only numbers, what is 10 plus 15?
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