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* A consent to release medical records will be requested if injuries were treated.
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
I hereby certify that all of the statements contained in the Complaint form are true and correct to the best of my knowledge and belief.
This field is not part of the form submission.
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