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Full Name:

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Type of Accident:
-----Accident and Illness OverseasAccident at schoolAccident at workAccidents in public placesCompensation for victims of violenceCycle accidentsDefective productsHead injuriesHoliday and travel disastersProduct liability in the UK or USAMotorcycle accidentsPedestrian accidentsMilitary accidentsRoad traffic accidentsSpinal injuriesSports related injuriesWhiplash injury

When were you injured?
----Within the last weekWithin the last monthWithin the last yearOver a year ago

Please provide a brief description of how you received your injuries (up to 500 characters):

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