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Submit injury claim
(800) 741-0415
Submit your injury claim
Where did the injury occur?
Address
Street Address
City
State
Did you report the incident?
Yes
No
Evidence upload
Photos/Videos
Receipt or bank statement (Proof of visit)
Did you get medical treatment?
Yes
No
Where did you receive your medical treatment?
Did they file a report? Upload file (Optional)
Your Full Name
Email
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Phone
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Submit Injury claim
(800) 741-0415
