{"text":"~Our\u00a7\u00e9f:c98ig\u00a5 UK e \n\/>\\ \u2018 - \ufb01\u00ab CL(...- \n\u2018ACCESS TO'PERSONAL INFORMATION \n;rNAME IN FULL; (lncluding former name if changed since accident) \nPN . ) . - \nFREnee Dane Mo L \na; :\u2019?\u20183 Date of Birth: \\Q 1CR X Q Date of Accident: _| S \/ Q \/ \u00e9t . \nNatronaf Insurance: Number@@\ufb01 5&@ \n. Address and Postcode ( Including former address if changed since \u00e9ccident) \n...... A2 CR m.r\\\/rem \n\u2014 \n.................................. \n----------------------------------------------- \n. If YES, please state how long: ~ ........Months ........ Weeks . :1\u2014 Dayy \nEmployer\u2019s name and address. mm LCb\\\u2014GLD .............................. \nAndusial. 5,\u2018.\u20193:@.3&:2_ ..... et \nNature of Duties. PL-C.\\QGI\" \/Ebc,\\(\ufb01f ............. O S OTOS \nDid you attend a NHS Hospital as a rest_ilt of the accident? B\/ NO \nWere any X-rays taken? \"EI NO \u2018 ' \n~ Please give full name and address of the Hospital: \n...................................................................................................................... \n..................................................................................................................... \nPlease tell us about any injury sustamed In as much details as possibie: \n\u00ae \\. . \\ Bhe Blssue.. i mm& | \n\\)QOD&DO .:[Xr'ticmved. (Yedxc(gbm Logo.Y \u201c@%\u2018%\u2018a\ufb01\u201c iy \nOwn General Practitioner's name & address: ....~........ ..o D o S \n- Dr. MGhee, Kilsyhn, Weallhy Cerre, K. \nL CONSENT FOR GENERAL PRACTITIONER\u2019S \/ HOSPITAL \/ EMPLOYMENT RECORDS ] \nI hereby consent to the disclosure of my Employment and \/or Hosp ital Records and \/ or \nGeneral Practitioner's records (past & present) to DIRECT LINE GROUP SERVICES or \nto their appointed representative for the purpose of supporting my claim for \ncompensation, \nSlgned...\".e..\/.\u2018{ Uerrvnnn.. e Daied: \u201c4 G 'S \nNON RECCYERT \n!\\ ' \nPLEASE COMPLETE AS FULLY AS POSSIBLE TO AID THE SWIFT;PROCESSING OF YOUR CLAM \n\" . * Best Practice \n(_\u2014;L\/\\(\u2018:\u2018G\u2018 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