Personal Injury Protection
Personal Info
First Name
Last Name
General Information
Name of Company responsible for payment.
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Date of Accident
Claims Manager
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Claim Number
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Name of Claims Manager
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Who is the referring doctor?
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Do you still have availability on your PIP?
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No
Have you recieved massage using this PIP claim previous to your first massage at Reflex Massage?
Yes
No
Are you using an attorney?
Yes
No
Law firm representing you?
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Name of Attorney
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Attorney Phone Number
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Personal Injury Protection Guarantee
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