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The document is a Citizen Incident Notification form for reporting incidents related to the Montana Department of Transportation. It requires claimants to provide personal information, details about the incident, damages, and any personal injuries. The form also includes sections for vehicle information and witness details. Claimants are instructed to submit the form along with relevant documentation to the Occupational Safety & Health Bureau, which will then be processed by the Risk Management and Tort Defense Division.

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