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Click ‘Get Form’ to open the No-Fault Intake Form in our editor.
Begin by filling in your personal information, including your name, date of birth, and contact details. Ensure accuracy as this information is crucial for processing your claim.
Next, provide details about the accident. Fill in the date of the accident, accident state, and insurance information including policy number and claim number.
In the section regarding symptoms, indicate when they first appeared and whether you have a history of similar conditions. Initial where required to confirm your responses.
Complete the authorization sections by signing and dating where indicated. This includes consent for treatment and assignment of benefits.
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