Name

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Email Address

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Phone Number

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When and where did the accident occur?

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What were the conditions? Light/Dark? Wet/Dry? Snow/Ice?

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Were you the driver or a passenger on the motorcycle?

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Who owns the motorcycle?

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Is it insured?
yes    no
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Were you wearing a helmet when the accident occurred?
yes    no
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Was another vehicle involved in the accident?
yes    no
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If not, could you tell why the accident happened?
yes    no
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Did you notice any wobbling or other problem with control or maneuverability of the motorcycle just before the accident occurred?
yes    no
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Who is the manufacturer of the motorcycle?

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What model is it?

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Did the police come to the scene of the accident?
yes    no
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Were any citations issued or arrests made?
yes    no
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In your opinion, was alcohol a factor in causing the accident?
yes    no
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Do you have a copy of the police report?
yes    no
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Were you injured in the accident?
yes    no
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Were you taken to the hospital?
yes    no
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If so, how were you taken there?

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What medical treatment have you received? Are you currently receiving medical treatment?

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Were you insured on the day of the accident?
yes    no
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Was the driver of the other vehicle(s) insured?
yes    no
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Are you currently under a physician's care for the injuries sustained in the accident?
yes    no
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