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Ndicate if activity was part of normal duties: Accident Location Narrative (if no street address): Witness Name & Business Phone Number: Initial Treatment Code MEDICAL Accident Site County/Parish: Initial Medical Provider Name: (check one): no medical treatment (0) minor/on-site treatment (1) clinic/hospital visit (2) emergency care (3) hospitalization 24 hours (4) future medical treatment/lost time anticipated (5) Preparer s Name & Title: IAIABC FORM 1.2 (12/98) Managed Care Orga.

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