)]TJ /F2 1 Tf 6 0 0 6 69.5905 374.3771 Tm [(F)17.6(irst name)]TJ /F1 1 Tf 7 0 0 7 69.5905 366.2828 Tm [(Date de naissance : )-532(. . . . . . V)54.9(ous pouvez donc l'utiliser en suivant la traduction )]TJ -16.2881 -1.1111 TD 0.0278 Tw [(de rubrique en rubrique \(elles sont num�rot�es � cet ef)17.8(fet\) sur votre propre carnet. . . . . . )]TJ /F2 1 Tf 6 0 0 6 137.4372 335.1885 Tm -0.0001 Tc 0.0000 Tw (Country)Tj /F1 1 Tf 7 0 0 7 69.5905 328.1885 Tm -0.0002 Tc 0.0278 Tw [(T�l ou email )-59.8(. )Tj 0.9169 -1.2 TD (Complete question 5. . . )]TJ -21.8634 -1.2237 TD [(Agence \(ou bureau, ou courtier\) : )-420.8(. )Tj T* 0.0000 Tc 0.0000 Tw (1)Tj 4.75 0 0 5 97.474 117.092 Tm -0.0002 Tc (ers)Tj 9.5 0 0 10 106.9735 113.5607 Tm -0.0001 Tc 0.0278 Tw (soins ou hospitalisation �)Tj -1.5559 -1.6 TD (Nature et gravit� des blessures)Tj ET 1 w /GS2 gs 250.495 282.348 m 250.495 87.808 l 446.126 281.293 m 446.126 86.193 l S BT 10 0 0 10 71.7373 58.1614 Tm /GS3 gs 0.0276 Tc 0.0000 Tw [(A)-7863.5(l)27.8(e)27.8( 2)27.8(0)27.8( )]TJ 9 0 0 9 280.1245 58.1614 Tm -0.0001 Tc 0.0278 Tw (Signature de l�assur�)Tj ET 0 0 0 1 K 0.5 w /GS2 gs 504.040 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246.830 250.390 246.860 250.360 c 246.890 250.340 246.910 250.300 246.910 250.260 c 246.910 250.220 246.890 250.180 246.860 250.150 c 246.830 250.120 246.800 250.110 246.760 250.110 c f* 1 i 110.790 235.200 m 246.360 235.200 l S 110.690 235.050 m 110.650 235.050 110.610 235.060 110.590 235.090 c 110.560 235.120 110.540 235.160 110.540 235.200 c 110.540 235.240 110.560 235.280 110.590 235.300 c 110.610 235.330 110.650 235.350 110.690 235.350 c 110.730 235.350 110.770 235.330 110.800 235.300 c 110.830 235.280 110.840 235.240 110.840 235.200 c 110.840 235.160 110.830 235.120 110.800 235.090 c 110.770 235.060 110.730 235.050 110.690 235.050 c f* 3 i 246.760 235.050 m 246.720 235.050 246.680 235.060 246.650 235.090 c 246.620 235.120 246.610 235.160 246.610 235.200 c 246.610 235.240 246.620 235.280 246.650 235.300 c 246.680 235.330 246.720 235.350 246.760 235.350 c 246.800 235.350 246.830 235.330 246.860 235.300 c 246.890 235.280 246.910 235.240 246.910 235.200 c 246.910 235.160 246.890 235.120 246.860 235.090 c 246.830 235.060 246.800 235.050 246.760 235.050 c f* 1 i 128.490 217.460 m 246.370 217.460 l S 128.410 217.310 m 128.370 217.310 128.330 217.330 128.300 217.360 c 128.270 217.380 128.260 217.420 128.260 217.460 c 128.260 217.500 128.270 217.540 128.300 217.570 c 128.330 217.600 128.370 217.610 128.410 217.610 c 128.450 217.610 128.490 217.600 128.510 217.570 c 128.540 217.540 128.560 217.500 128.560 217.460 c 128.560 217.420 128.540 217.380 128.510 217.360 c 128.490 217.330 128.450 217.310 128.410 217.310 c f* 3 i 246.760 217.310 m 246.720 217.310 246.680 217.330 246.650 217.360 c 246.620 217.380 246.610 217.420 246.610 217.460 c 246.610 217.500 246.620 217.540 246.650 217.570 c 246.680 217.600 246.720 217.610 246.760 217.610 c 246.800 217.610 246.830 217.600 246.860 217.570 c 246.890 217.540 246.910 217.500 246.910 217.460 c 246.910 217.420 246.890 217.380 246.860 217.360 c 246.830 217.330 246.800 217.310 246.760 217.310 c f* 1 i 90.880 204.690 m 246.430 204.690 l S 90.850 204.540 m 90.810 204.540 90.770 204.550 90.740 204.580 c 90.720 204.610 90.700 204.650 90.700 204.690 c 90.700 204.730 90.720 204.760 90.740 204.790 c 90.770 204.820 90.810 204.840 90.850 204.840 c 90.890 204.840 90.930 204.820 90.960 204.790 c 90.980 204.760 91.000 204.730 91.000 204.690 c 91.000 204.650 90.980 204.610 90.960 204.580 c 90.930 204.550 90.890 204.540 90.850 204.540 c f* 3 i 246.760 204.540 m 246.720 204.540 246.680 204.550 246.650 204.580 c 246.620 204.610 246.610 204.650 246.610 204.690 c 246.610 204.730 246.620 204.760 246.650 204.790 c 246.680 204.820 246.720 204.840 246.760 204.840 c 246.800 204.840 246.830 204.820 246.860 204.790 c 246.890 204.760 246.910 204.730 246.910 204.690 c 246.910 204.650 246.890 204.610 246.860 204.580 c 246.830 204.550 246.800 204.540 246.760 204.540 c f* 1 i 110.790 192.980 m 246.780 192.980 l S 110.690 192.830 m 110.650 192.830 110.610 192.850 110.590 192.870 c 110.560 192.900 110.540 192.940 110.540 192.980 c 110.540 193.020 110.560 193.060 110.590 193.090 c 110.610 193.110 110.650 193.130 110.690 193.130 c 110.730 193.130 110.770 193.110 110.800 193.090 c 110.830 193.060 110.840 193.020 110.840 192.980 c 110.840 192.940 110.830 192.900 110.800 192.870 c 110.770 192.850 110.730 192.830 110.690 192.830 c f* 3 i 247.180 192.830 m 247.140 192.830 247.110 192.850 247.080 192.870 c 247.050 192.900 247.030 192.940 247.030 192.980 c 247.030 193.020 247.050 193.060 247.080 193.090 c 247.110 193.110 247.140 193.130 247.180 193.130 c 247.220 193.130 247.260 193.110 247.290 193.090 c 247.320 193.060 247.330 193.020 247.330 192.980 c 247.330 192.940 247.320 192.900 247.290 192.870 c 247.260 192.850 247.220 192.830 247.180 192.830 c f* 1 i 139.230 179.010 m 244.660 179.010 l S 139.160 178.860 m 139.120 178.860 139.080 178.870 139.050 178.900 c 139.020 178.930 139.010 178.970 139.010 179.010 c 139.010 179.050 139.020 179.090 139.050 179.110 c 139.080 179.140 139.120 179.160 139.160 179.160 c 139.200 179.160 139.230 179.140 139.260 179.110 c 139.290 179.090 139.310 179.050 139.310 179.010 c 139.310 178.970 139.290 178.930 139.260 178.900 c 139.230 178.870 139.200 178.860 139.160 178.860 c f* 3 i 245.030 178.860 m 244.990 178.860 244.960 178.870 244.930 178.900 c 244.900 178.930 244.880 178.970 244.880 179.010 c 244.880 179.050 244.900 179.090 244.930 179.110 c 244.960 179.140 244.990 179.160 245.030 179.160 c 245.070 179.160 245.110 179.140 245.140 179.110 c 245.170 179.090 245.180 179.050 245.180 179.010 c 245.180 178.970 245.170 178.930 245.140 178.900 c 245.110 178.870 245.070 178.860 245.030 178.860 c f* 1 i 219.300 131.320 m 243.550 131.320 l S 219.230 131.170 m 219.190 131.170 219.150 131.190 219.120 131.220 c 219.100 131.250 219.080 131.280 219.080 131.320 c 219.080 131.360 219.100 131.400 219.120 131.430 c 219.150 131.460 219.190 131.470 219.230 131.470 c 219.270 131.470 219.310 131.460 219.340 131.430 c 219.360 131.400 219.380 131.360 219.380 131.320 c 219.380 131.280 219.360 131.250 219.340 131.220 c 219.310 131.190 219.270 131.170 219.230 131.170 c f* 3 i 243.920 131.170 m 243.880 131.170 243.840 131.190 243.820 131.220 c 243.790 131.250 243.770 131.280 243.770 131.320 c 243.770 131.360 243.790 131.400 243.820 131.430 c 243.840 131.460 243.880 131.470 243.920 131.470 c 243.960 131.470 244.000 131.460 244.030 131.430 c 244.060 131.400 244.070 131.360 244.070 131.320 c 244.070 131.280 244.060 131.250 244.030 131.220 c 244.000 131.190 243.960 131.170 243.920 131.170 c f* 1 i 88.130 85.800 m 242.560 85.800 l S 88.100 85.650 m 88.060 85.650 88.030 85.660 88.000 85.690 c 87.970 85.720 87.950 85.760 87.950 85.800 c 87.950 85.840 87.970 85.870 88.000 85.900 c 88.030 85.930 88.060 85.950 88.100 85.950 c 88.140 85.950 88.180 85.930 88.210 85.900 c 88.240 85.870 88.250 85.840 88.250 85.800 c 88.250 85.760 88.240 85.720 88.210 85.690 c 88.180 85.660 88.140 85.650 88.100 85.650 c f* 3 i 242.880 85.650 m 242.840 85.650 242.810 85.660 242.780 85.690 c 242.750 85.720 242.730 85.760 242.730 85.800 c 242.730 85.840 242.750 85.870 242.780 85.900 c 242.810 85.930 242.840 85.950 242.880 85.950 c 242.920 85.950 242.960 85.930 242.990 85.900 c 243.020 85.870 243.030 85.840 243.030 85.800 c 243.030 85.760 243.020 85.720 242.990 85.690 c 242.960 85.660 242.920 85.650 242.880 85.650 c f* 1 i 252.620 250.260 m 621.150 250.260 l S 252.550 250.110 m 252.510 250.110 252.470 250.120 252.440 250.150 c 252.410 250.180 252.400 250.220 252.400 250.260 c 252.400 250.300 252.410 250.340 252.440 250.360 c 252.470 250.390 252.510 250.410 252.550 250.410 c 252.590 250.410 252.630 250.390 252.660 250.360 c 252.680 250.340 252.700 250.300 252.700 250.260 c 252.700 250.220 252.680 250.180 252.660 250.150 c 252.630 250.120 252.590 250.110 252.550 250.110 c f* 3 i 621.520 250.110 m 621.480 250.110 621.440 250.120 621.410 250.150 c 621.390 250.180 621.370 250.220 621.370 250.260 c 621.370 250.300 621.390 250.340 621.410 250.360 c 621.440 250.390 621.480 250.410 621.520 250.410 c 621.560 250.410 621.600 250.390 621.630 250.360 c 621.650 250.340 621.670 250.300 621.670 250.260 c 621.670 250.220 621.650 250.180 621.630 250.150 c 621.600 250.120 621.560 250.110 621.520 250.110 c f* 1 i 252.490 234.820 m 621.030 234.820 l S 252.430 234.670 m 252.390 234.670 252.350 234.690 252.320 234.720 c 252.290 234.740 252.280 234.780 252.280 234.820 c 252.280 234.860 252.290 234.900 252.320 234.930 c 252.350 234.960 252.390 234.970 252.430 234.970 c 252.460 234.970 252.500 234.960 252.530 234.930 c 252.560 234.900 252.580 234.860 252.580 234.820 c 252.580 234.780 252.560 234.740 252.530 234.720 c 252.500 234.690 252.460 234.670 252.430 234.670 c f* 3 i 621.400 234.670 m 621.360 234.670 621.320 234.690 621.290 234.720 c 621.260 234.740 621.250 234.780 621.250 234.820 c 621.250 234.860 621.260 234.900 621.290 234.930 c 621.320 234.960 621.360 234.970 621.400 234.970 c 621.440 234.970 621.470 234.960 621.500 234.930 c 621.530 234.900 621.550 234.860 621.550 234.820 c 621.550 234.780 621.530 234.740 621.500 234.720 c 621.470 234.690 621.440 234.670 621.400 234.670 c f* 1 i 252.730 216.920 m 621.270 216.920 l S 252.670 216.770 m 252.630 216.770 252.590 216.790 252.560 216.820 c 252.530 216.850 252.520 216.880 252.520 216.920 c 252.520 216.960 252.530 217.000 252.560 217.030 c 252.590 217.060 252.630 217.070 252.670 217.070 c 252.710 217.070 252.740 217.060 252.770 217.030 c 252.800 217.000 252.820 216.960 252.820 216.920 c 252.820 216.880 252.800 216.850 252.770 216.820 c 252.740 216.790 252.710 216.770 252.670 216.770 c f* 3 i 621.640 216.770 m 621.600 216.770 621.560 216.790 621.530 216.820 c 621.500 216.850 621.490 216.880 621.490 216.920 c 621.490 216.960 621.500 217.000 621.530 217.030 c 621.560 217.060 621.600 217.070 621.640 217.070 c 621.680 217.070 621.720 217.060 621.740 217.030 c 621.770 217.000 621.790 216.960 621.790 216.920 c 621.790 216.880 621.770 216.850 621.740 216.820 c 621.720 216.790 621.680 216.770 621.640 216.770 c f* 1 i 253.910 204.570 m 622.450 204.570 l S 253.840 204.420 m 253.800 204.420 253.760 204.440 253.740 204.470 c 253.710 204.490 253.690 204.530 253.690 204.570 c 253.690 204.610 253.710 204.650 253.740 204.680 c 253.760 204.710 253.800 204.720 253.840 204.720 c 253.880 204.720 253.920 204.710 253.950 204.680 c 253.980 204.650 253.990 204.610 253.990 204.570 c 253.990 204.530 253.980 204.490 253.950 204.470 c 253.920 204.440 253.880 204.420 253.840 204.420 c f* 3 i 622.810 204.420 m 622.770 204.420 622.730 204.440 622.710 204.470 c 622.680 204.490 622.660 204.530 622.660 204.570 c 622.660 204.610 622.680 204.650 622.710 204.680 c 622.730 204.710 622.770 204.720 622.810 204.720 c 622.850 204.720 622.890 204.710 622.920 204.680 c 622.950 204.650 622.960 204.610 622.960 204.570 c 622.960 204.530 622.950 204.490 622.920 204.470 c 622.890 204.440 622.850 204.420 622.810 204.420 c f* 1 i 253.280 191.890 m 621.810 191.890 l S 253.210 191.740 m 253.170 191.740 253.130 191.760 253.100 191.790 c 253.080 191.810 253.060 191.850 253.060 191.890 c 253.060 191.930 253.080 191.970 253.100 192.000 c 253.130 192.030 253.170 192.040 253.210 192.040 c 253.250 192.040 253.290 192.030 253.320 192.000 c 253.350 191.970 253.360 191.930 253.360 191.890 c 253.360 191.850 253.350 191.810 253.320 191.790 c 253.290 191.760 253.250 191.740 253.210 191.740 c f* 3 i 622.180 191.740 m 622.140 191.740 622.100 191.760 622.080 191.790 c 622.050 191.810 622.030 191.850 622.030 191.890 c 622.030 191.930 622.050 191.970 622.080 192.000 c 622.100 192.030 622.140 192.040 622.180 192.040 c 622.220 192.040 622.260 192.030 622.290 192.000 c 622.320 191.970 622.330 191.930 622.330 191.890 c 622.330 191.850 622.320 191.810 622.290 191.790 c 622.260 191.760 622.220 191.740 622.180 191.740 c f* 1 i 253.910 178.190 m 622.450 178.190 l S 253.840 178.040 m 253.800 178.040 253.760 178.060 253.740 178.080 c 253.710 178.110 253.690 178.150 253.690 178.190 c 253.690 178.230 253.710 178.270 253.740 178.300 c 253.760 178.320 253.800 178.340 253.840 178.340 c 253.880 178.340 253.920 178.320 253.950 178.300 c 253.980 178.270 253.990 178.230 253.990 178.190 c 253.990 178.150 253.980 178.110 253.950 178.080 c 253.920 178.060 253.880 178.040 253.840 178.040 c f* 3 i 622.810 178.040 m 622.770 178.040 622.730 178.060 622.710 178.080 c 622.680 178.110 622.660 178.150 622.660 178.190 c 622.660 178.230 622.680 178.270 622.710 178.300 c 622.730 178.320 622.770 178.340 622.810 178.340 c 622.850 178.340 622.890 178.320 622.920 178.300 c 622.950 178.270 622.960 178.230 622.960 178.190 c 622.960 178.150 622.950 178.110 622.920 178.080 c 622.890 178.060 622.850 178.040 622.810 178.040 c f* 1 i 253.270 119.880 m 621.810 119.880 l S 253.200 119.730 m 253.160 119.730 253.130 119.740 253.100 119.770 c 253.070 119.800 253.050 119.840 253.050 119.880 c 253.050 119.920 253.070 119.960 253.100 119.980 c 253.130 120.010 253.160 120.030 253.200 120.030 c 253.240 120.030 253.280 120.010 253.310 119.980 c 253.340 119.960 253.350 119.920 253.350 119.880 c 253.350 119.840 253.340 119.800 253.310 119.770 c 253.280 119.740 253.240 119.730 253.200 119.730 c f* 3 i 622.170 119.730 m 622.130 119.730 622.100 119.740 622.070 119.770 c 622.040 119.800 622.020 119.840 622.020 119.880 c 622.020 119.920 622.040 119.960 622.070 119.980 c 622.100 120.010 622.130 120.030 622.170 120.030 c 622.210 120.030 622.250 120.010 622.280 119.980 c 622.310 119.960 622.320 119.920 622.320 119.880 c 622.320 119.840 622.310 119.800 622.280 119.770 c 622.250 119.740 622.210 119.730 622.170 119.730 c f* 1 i 254.860 104.550 m 623.400 104.550 l S 254.790 104.400 m 254.750 104.400 254.720 104.410 254.690 104.440 c 254.660 104.470 254.640 104.510 254.640 104.550 c 254.640 104.590 254.660 104.620 254.690 104.650 c 254.720 104.680 254.750 104.700 254.790 104.700 c 254.830 104.700 254.870 104.680 254.900 104.650 c 254.930 104.620 254.940 104.590 254.940 104.550 c 254.940 104.510 254.930 104.470 254.900 104.440 c 254.870 104.410 254.830 104.400 254.790 104.400 c f* 3 i 623.760 104.400 m 623.720 104.400 623.690 104.410 623.660 104.440 c 623.630 104.470 623.610 104.510 623.610 104.550 c 623.610 104.590 623.630 104.620 623.660 104.650 c 623.690 104.680 623.720 104.700 623.760 104.700 c 623.800 104.700 623.840 104.680 623.870 104.650 c 623.900 104.620 623.910 104.590 623.910 104.550 c 623.910 104.510 623.900 104.470 623.870 104.440 c 623.840 104.410 623.800 104.400 623.760 104.400 c f* 1 i 254.860 90.800 m 623.400 90.800 l S 254.790 90.650 m 254.750 90.650 254.720 90.660 254.690 90.690 c 254.660 90.720 254.640 90.760 254.640 90.800 c 254.640 90.840 254.660 90.870 254.690 90.900 c 254.720 90.930 254.750 90.950 254.790 90.950 c 254.830 90.950 254.870 90.930 254.900 90.900 c 254.930 90.870 254.940 90.840 254.940 90.800 c 254.940 90.760 254.930 90.720 254.900 90.690 c 254.870 90.660 254.830 90.650 254.790 90.650 c f* 3 i 623.760 90.650 m 623.720 90.650 623.690 90.660 623.660 90.690 c 623.630 90.720 623.610 90.760 623.610 90.800 c 623.610 90.840 623.630 90.870 623.660 90.900 c 623.690 90.930 623.720 90.950 623.760 90.950 c 623.800 90.950 623.840 90.930 623.870 90.900 c 623.900 90.870 623.910 90.840 623.910 90.800 c 623.910 90.760 623.900 90.720 623.870 90.690 c 623.840 90.660 623.800 90.650 623.760 90.650 c f* BT /F2 1 Tf 7 0 0 7 92.6564 822.1523 Tm 0 0 0 1 k /GS3 gs -0.0001 Tc 0.0277 Tw [(Name of insured)-31527.8(Occupation)-16302.4(T)99.8(e)0(l n�)]TJ 0.1469 -14.9042 TD [(Cir)11.9(cumstances of the accident)]TJ -0.517 -29.2794 TD [(Has a report been made b)17.7(y)0( Highw)17.7(a)29.7(y)0( police)-30485.5(City police)]TJ ET 0 0 0 1 K 0 J 0.5 w []0 d /GS2 gs 1 i 308.510 795.810 39.600 -10.960 re 468.697 512.867 m S /Cs7 CS 1 SCN 334.786 796.054 m 334.786 785.224 l S BT /F13 1 Tf 9 0 0 9 310.6515 787.446 Tm /GS3 gs 0.0000 Tw (NON)Tj ET 0 0 0 1 K /GS2 gs 264.010 784.580 39.600 -10.960 re 330.646 787.446 m S /Cs7 CS 1 SCN 290.282 784.829 m 290.282 773.999 l S BT /F12 1 Tf 8 0 0 8 268.1454 776.9495 Tm /GS3 gs 0.0000 Tc (YES)Tj ET 0 0 0 1 K /GS2 gs 308.510 784.470 39.600 -10.960 re 284.153 776.950 m S /Cs7 CS 1 SCN 334.785 784.716 m 334.785 773.886 l S BT 8 0 0 8 314.65 776.8362 Tm /GS3 gs -0.0002 Tc (NO)Tj ET 0 0 0 1 K /GS2 gs 219.840 769.690 39.600 -10.960 re 326.646 776.836 m S /Cs7 CS 1 SCN 246.119 769.941 m 246.119 759.111 l S BT /F13 1 Tf 9 0 0 9 223.9796 761.333 Tm /GS3 gs (OUI)Tj ET 0 0 0 1 K /GS2 gs 264.340 769.580 39.600 -10.960 re 239.976 761.333 m S /Cs7 CS 1 SCN 290.612 769.828 m 290.612 758.998 l S BT 9 0 0 9 266.481 761.2198 Tm /GS3 gs -0.0001 Tc (NON)Tj ET 0 0 0 1 K /GS2 gs 219.840 758.360 39.600 -10.970 re 286.475 761.220 m S /Cs7 CS 1 SCN 246.117 758.603 m 246.117 747.773 l S BT /F12 1 Tf 8 0 0 8 223.9749 750.7233 Tm /GS3 gs 0.0000 Tc (YES)Tj ET 0 0 0 1 K /GS2 gs 264.340 758.240 39.600 -10.960 re 239.983 750.723 m S /Cs7 CS 1 SCN 290.611 758.489 m 290.611 747.659 l S BT 8 0 0 8 270.4795 750.61 Tm /GS3 gs -0.0002 Tc (NO)Tj ET 0 0 0 1 K /GS2 gs 538.970 790.730 39.600 -10.960 re 282.476 750.610 m S /Cs7 CS 1 SCN 565.244 790.978 m 565.244 780.148 l S BT /F13 1 Tf 9 0 0 9 543.1108 782.3689 Tm /GS3 gs (OUI)Tj ET 0 0 0 1 K /GS2 gs 583.470 790.620 39.600 -10.970 re 559.108 782.369 m S /Cs7 CS 1 SCN 609.747 790.865 m 609.747 780.035 l S BT 9 0 0 9 585.6122 782.2557 Tm /GS3 gs (NON)Tj ET 0 0 0 1 K /GS2 gs 538.970 779.390 39.600 -10.960 re 605.606 782.256 m S /Cs7 CS 1 SCN 565.243 779.640 m 565.243 768.810 l S BT /F12 1 Tf 8 0 0 8 543.106 771.7592 Tm /GS3 gs 0.0000 Tc (YES)Tj ET 0 0 0 1 K /GS2 gs 583.470 779.280 39.600 -10.960 re 559.114 771.759 m S /Cs7 CS 1 SCN 609.746 779.526 m 609.746 768.696 l S BT 8 0 0 8 589.6107 771.6459 Tm /GS3 gs -0.0002 Tc (NO)Tj ET 0 0 0 1 K /GS2 gs 314.640 531.760 39.600 -10.970 re 601.607 771.646 m S /Cs7 CS 1 SCN 340.917 532.003 m 340.917 521.173 l S BT /F13 1 Tf 9 0 0 9 318.7795 523.3952 Tm /GS3 gs (OUI)Tj ET 0 0 0 1 K /GS2 gs 359.140 531.640 39.600 -10.960 re 334.776 523.395 m S /Cs7 CS 1 SCN 385.420 531.890 m 385.420 521.060 l S BT 9 0 0 9 361.2809 523.282 Tm /GS3 gs -0.0001 Tc (NON)Tj ET 0 0 0 1 K /GS2 gs 314.640 520.420 39.600 -10.960 re 381.275 523.282 m S /Cs7 CS 1 SCN 340.915 520.665 m 340.915 509.835 l S BT /F12 1 Tf 8 0 0 8 318.7748 512.7854 Tm /GS3 gs 0.0000 Tc (YES)Tj ET 0 0 0 1 K /GS2 gs 359.140 520.310 39.600 -10.970 re 334.783 512.785 m S /Cs7 CS 1 SCN 385.418 520.551 m 385.418 509.721 l S BT 8 0 0 8 365.2794 512.6721 Tm /GS3 gs -0.0002 Tc (NO)Tj ET 0 0 0 1 K /GS2 gs 536.580 532.510 39.600 -10.960 re 377.276 512.672 m S /Cs7 CS 1 SCN 562.856 532.755 m 562.856 521.925 l S BT /F13 1 Tf 9 0 0 9 540.7197 524.1464 Tm /GS3 gs (OUI)Tj ET 0 0 0 1 K /GS2 gs 581.080 532.400 39.600 -10.970 re 556.716 524.146 m S /Cs7 CS 1 SCN 607.359 532.641 m 607.359 521.811 l S BT 9 0 0 9 583.2211 524.0332 Tm /GS3 gs (NON)Tj ET 0 0 0 1 K /GS2 gs 536.580 521.170 39.600 -10.960 re 603.215 524.033 m S /Cs7 CS 1 SCN 562.854 521.416 m 562.854 510.586 l S BT /F12 1 Tf 8 0 0 8 540.715 513.5366 Tm /GS3 gs 0.0000 Tc (YES)Tj ET 0 0 0 1 K /GS2 gs 581.080 521.060 39.600 -10.970 re 556.723 513.537 m S /Cs7 CS 1 SCN 607.357 521.303 m 607.357 510.473 l S BT 8 0 0 8 587.2196 513.4233 Tm /GS3 gs -0.0002 Tc (NO)Tj ET 0 0 0 1 K /GS2 gs 187.480 507.000 39.590 -10.970 re 599.216 513.423 m S /Cs7 CS 1 SCN 213.752 507.248 m 213.752 496.408 l S BT /F13 1 Tf 9 0 0 9 191.6147 498.6346 Tm /GS3 gs (OUI)Tj ET 0 0 0 1 K /GS2 gs 231.980 506.880 39.590 -10.960 re 207.611 498.635 m S /Cs7 CS 1 SCN 258.246 507.134 m 258.246 496.294 l S BT 9 0 0 9 234.1161 498.5213 Tm /GS3 gs -0.0001 Tc (NON)Tj ET 0 0 0 1 K /GS2 gs 187.480 495.660 39.590 -10.960 re 254.110 498.521 m S /Cs7 CS 1 SCN 213.751 495.909 m 213.751 485.069 l S BT /F12 1 Tf 8 0 0 8 191.61 488.0248 Tm /GS3 gs 0.0000 Tc (YES)Tj ET 0 0 0 1 K /GS2 gs 231.980 495.540 39.590 -10.960 re 207.618 488.025 m S /Cs7 CS 1 SCN 258.254 495.796 m 258.254 484.956 l S BT 8 0 0 8 238.1146 487.9115 Tm /GS3 gs -0.0002 Tc (NO)Tj /F2 1 Tf 7 0 0 7 291.215 486.6713 Tm -0.0001 Tc 0.0277 Tw [(In the affirmati)17.7(v)11.9(e)0( : patrol or P)44.8(olice Station of)]TJ -28.3168 -25.4575 TD [(Material damage other than to v)11.9(ehicles )36.8(A and B \(nature and extend, name and address of o)11.9(wner\))]TJ 0.376 19.3404 TD [(Estimate of damage Name and address of the gar)11.9(age w)17.7(here the v)11.9(ehicle can be visible)]TJ ET 0.3 w /GS2 gs 484.870 405.950 m 626.600 405.950 l S 0 0 0 1 K 0.5 w 298.470 153.960 39.600 -10.970 re 427.096 443.851 m S /Cs7 CS 1 SCN 324.746 154.204 m 324.746 143.374 l S BT /F13 1 Tf 9 0 0 9 302.6095 145.5956 Tm /GS3 gs -0.0002 Tc 0.0000 Tw (OUI)Tj ET 0 0 0 1 K /GS2 gs 342.970 153.840 39.600 -10.960 re 318.606 145.596 m S /Cs7 CS 1 SCN 369.249 154.090 m 369.249 143.260 l S BT 9 0 0 9 345.1108 145.4823 Tm /GS3 gs -0.0001 Tc (NON)Tj ET 0 0 0 1 K /GS2 gs 298.470 142.620 39.600 -10.960 re 365.105 145.482 m S /Cs7 CS 1 SCN 324.745 142.865 m 324.745 132.035 l S BT /F12 1 Tf 8 0 0 8 302.6047 134.9858 Tm /GS3 gs 0.0000 Tc (YES)Tj ET 0 0 0 1 K /GS2 gs 342.970 142.510 39.600 -10.970 re 318.613 134.986 m S /Cs7 CS 1 SCN 369.248 142.752 m 369.248 131.922 l S BT 8 0 0 8 349.1094 134.8725 Tm /GS3 gs -0.0002 Tc (NO)Tj ET 0 0 0 1 K /GS2 gs 495.750 152.840 39.600 -10.960 re 361.106 134.872 m S /Cs7 CS 1 SCN 522.022 153.092 m 522.022 142.252 l S BT /F13 1 Tf 9 0 0 9 499.8866 144.4771 Tm /GS3 gs (OUI)Tj ET 0 0 0 1 K /GS2 gs 540.250 152.730 39.600 -10.970 re 515.883 144.477 m S /Cs7 CS 1 SCN 566.525 152.979 m 566.525 142.139 l S BT 9 0 0 9 542.3879 144.3639 Tm /GS3 gs (NON)Tj ET 0 0 0 1 K /GS2 gs 495.750 141.500 39.600 -10.960 re 562.382 144.364 m S /Cs7 CS 1 SCN 522.020 141.754 m 522.020 130.914 l S BT /F12 1 Tf 8 0 0 8 499.8818 133.8673 Tm /GS3 gs 0.0000 Tc (YES)Tj ET 0 0 0 1 K /GS2 gs 540.250 141.390 39.600 -10.970 re 515.890 133.867 m S /Cs7 CS 1 SCN 566.523 141.640 m 566.523 130.800 l S BT 8 0 0 8 546.3865 133.7541 Tm /GS3 gs -0.0002 Tc (NO)Tj ET 1.5 w /GS2 gs 251.340 266.710 m 623.030 266.710 l S 0.5 w 265.032 267.059 m 265.032 272.379 l 279.206 267.066 m 279.206 272.376 l 293.379 267.063 m 293.379 272.383 l 307.552 267.060 m 307.552 272.380 l 321.725 267.066 m 321.725 272.376 l 335.899 267.063 m 335.899 272.383 l 350.072 267.060 m 350.072 272.380 l 364.245 267.066 m 364.245 272.376 l 378.418 267.063 m 378.418 272.373 l 392.591 267.060 m 392.591 272.380 l 406.765 267.067 m 406.765 272.377 l 420.938 267.064 m 420.938 272.374 l 435.111 267.060 m 435.111 272.380 l 458.284 267.067 m 458.284 272.377 l 472.458 267.064 m 472.458 272.374 l 486.631 267.061 m 486.631 272.381 l 500.804 267.067 m 500.804 272.377 l 514.977 267.064 m 514.977 272.374 l 529.151 267.061 m 529.151 272.381 l 543.324 267.068 m 543.324 272.378 l 557.497 267.064 m 557.497 272.374 l 571.670 267.061 m 571.670 272.381 l 585.843 267.068 m 585.843 272.378 l 600.017 267.065 m 600.017 272.375 l 614.190 267.062 m 614.190 272.382 l S 81.290 59.110 m 155.520 59.110 l 167.390 58.050 m 211.860 58.050 l 226.910 58.580 m 251.340 58.580 l S BT /F2 1 Tf 7 0 0 7 93.685 260.6902 Tm /GS3 gs -0.0001 Tc 0.0277 Tw [(W)36.8(ounded name)]TJ -0.1995 -4.7515 TD 0.0000 Tc 0.0000 Tw (Age)Tj 0 -2.4475 TD -0.0001 Tc (Address)Tj 0 -5.3855 TD (Occupation)Tj 0 -3.4286 TD 0.0278 Tw [(P)44.9(osition at the time of the accident : passenger of )]TJ 0 -1 TD [(car )36.7(A or B)23.8(,)0.1( c)23.8(yclist, pedestrian, etc)]TJ 0 -5 TD [(F)17.7(irst aid and hospitalization at)]TJ 0 -2.2857 TD [(Nature and extent of w)11.9(ounds)]TJ ET 1 J 0.3 w [0.000 0.600 ]0.001 d /GS2 gs 254.780 164.200 m 623.320 164.200 l S /Cs7 cs 1 scn 254.720 164.050 m 254.680 164.050 254.640 164.060 254.610 164.090 c 254.580 164.120 254.570 164.160 254.570 164.200 c 254.570 164.240 254.580 164.270 254.610 164.300 c 254.640 164.330 254.680 164.350 254.720 164.350 c 254.760 164.350 254.790 164.330 254.820 164.300 c 254.850 164.270 254.870 164.240 254.870 164.200 c 254.870 164.160 254.850 164.120 254.820 164.090 c 254.790 164.060 254.760 164.050 254.720 164.050 c f* 3 i 623.690 164.050 m 623.650 164.050 623.610 164.060 623.580 164.090 c 623.550 164.120 623.540 164.160 623.540 164.200 c 623.540 164.240 623.550 164.270 623.580 164.300 c 623.610 164.330 623.650 164.350 623.690 164.350 c 623.730 164.350 623.760 164.330 623.790 164.300 c 623.820 164.270 623.840 164.240 623.840 164.200 c 623.840 164.160 623.820 164.120 623.790 164.090 c 623.760 164.060 623.730 164.050 623.690 164.050 c f* BT 7 0 0 7 93.685 794.3584 Tm 0 0 0 1 k /GS3 gs [(Dri)17.7(v)11.9(er of the v)11.9(ehicle)]TJ 47.784 -0.2814 TD 0.0276 Tc 0.0000 Tw [(I)27.8(s)27.7( h)27.7(e)27.7( :)27.7( S)27.7(i)27.8(n)27.7(g)27.8(l)27.8(e)27.7( m)27.7(a)27.8(r)27.7(r)27.8(i)27.7(e)27.8(d)27.7( o)27.7(t)27.8(h)27.7(e)27.7(r)]TJ -47.8873 -2.3508 TD -0.0001 Tc 0.0277 Tw [(Is he / she the usual dri)17.7(v)11.9(er of the v)11.9(ehicle Does he / )]TJ 44.6347 0 TD (she usually reside with the insured)Tj -44.6347 -3.6445 TD [(Is he a salaried emplo)11.8(y)17.7(ee of the insurred If not, in w)17.8(hic)17.7(h capacity did he dri)17.7(v)11.9(e)]TJ 48.2467 0 TD [( the v)11.8(ehicle)]TJ -48.494 -37.5579 TD [(Declar)11.8(ation to the police)]TJ 0.3507 -3.4498 TD [(Insured v)11.9(ehicle: usual parking place)]TJ 27.9415 -8.1936 TD [(P)44.9(ossibly telephone)]TJ -28.144 -1.2148 TD (When ?
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