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Claim for Damage and/or Injury

Claim for Damage and/or Injury To:  _______________________________________ GENERAL INFORMATION 1.    Claimant (a)    Full name: ________________________________________ (b)    Address: __________________________________________ City: _________________________ County: _____________ State: _________________ Zip Code: __________________ (c)    Age: _______  (d) Marital status: _______________________ 2.    If claimant is married, name and address of spouse: __________________________________________________ __________________________________________________ AMOUNT OF CLAIM 3.    Amount claimed for property damage: […]