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दस्तावेज़
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OCR Page 1 of 2REPORT OF ACCIDENT
Accidents or Claims Must be Reported by Registered Mail or Telegraph within Forty-eight Hours
to Attorney in Fact at Illinois Automobile Insurance Exchange-Bloomington, III.
Date of Accident
191
Hour
A. M
P. M.
Where did accident happen?
How did accident happen?
State cause and describe fully; Fill out diagram
North
West
East
Give full name and address of all witnesses,
South
Name
Address
If personal injury accident fill out fully
Description of injury (Please be explicit)
Full name of person injured
Address
Age
What statement if any has injured person made and to whom?
Where was injured person taken after the accident?
Was accident fault of the injured person, if so, in what way?
When and where first treated for the injury?
Date
Place
By whom ?
Name
Address
Policy No
covering this accident issued to
Dated at
this
day of
191
Signature of Policy Holder
(Fill in both sides of this report)
ARGHIVES RECORDS SERVICE AND
Relations
belongs_to