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__extreme_junior_defendant_form.notice
__extreme_junior_defendant_form.event_notification
__extreme_junior_defendant_form.diagnosis_of_an_extreme_junior_or_illness
__extreme_junior_defendant_form.event_date
__extreme_junior_defendant_form.event_time
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__extreme_junior_defendant_form.state_of_occurrence
Yes
No
__extreme_junior_defendant_form.was_it_reported_to_police
__extreme_junior_defendant_form.event_description
Write text here…
__extreme_junior_defendant_form.information_about_insured_person
__extreme_junior_defendant_form.insured_personal_code_or_insurance_certificate_number
__extreme_junior_defendant_form.insured_name
__extreme_junior_defendant_form.insured_surname
__extreme_junior_defendant_form.insured_email
__extreme_junior_defendant_form.insured_phone
__extreme_junior_defendant_form.in_the_event_if_an_insured_event_transfer_the_insurance_benefit_to
__extreme_junior_defendant_form.beneficiary_coincides_with_the_insured
__extreme_junior_defendant_form.beneficiary_personal_company_code
__extreme_junior_defendant_form.beneficiary_first_name_last_name_company_name
__extreme_junior_defendant_form.beneficiary_bank_number
SUPPORTING DOCUMENTS
__extreme_junior_defendant_form.file_max_size_upload_text
__extreme_junior_defendant_form.document_plus_info
__extreme_junior_defendant_form.attach_a_document
__extreme_junior_defendant_form.attach_an_additional_document
__extreme_junior_defendant_form.notifier_details
__extreme_junior_defendant_form.reporter_is_policy_owner
__extreme_junior_defendant_form.reporter_personal_code
__extreme_junior_defendant_form.reporter_name
__extreme_junior_defendant_form.reporter_surname
Address*
__extreme_junior_defendant_form.reporter_phone
__extreme_junior_defendant_form.reporter_email
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__extreme_junior_defendant_form.submit