Did anyone appear injured?

Were you riding in a vehicle involved?

Which one?

Who do you think was responsible for the accident?

Your name:

Address:

City/State/Zip:

Phone:

Fecha

Lugar

Hubo algun herido?

Era usted pasajero en algun vehiculo del accidente?

Cual vehiculo?

En su opinion, quien tuvo la culpa en el accidente?

Su nombre?

Direccion?

Ciuda, Estado , Codigo postal

Telefono (trabajo)

(casa)

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