Rapha Claim Email <br />
<br />
RCC Number: [RCC]<br /> <br>
TITLE: [TITLE] <br /> <br>
FIRSTNAME: [FIRSTNAME] <br /> <br>
LASTNAME: [LASTNAME] <br /> <br>
DateOfBirth: [DateOfBirth] <br /> <br>
Email: [Email] <br /> <br>
Mobile: [Mobile] <br /> <br>
ADDRESS: [ADDRESS] <br /> <br>

TypeOfIncident: [TypeOfIncident] <br /> <br>
DateOfIncident: [DateOfIncident] <br /> <br>
Circumstances: [Circumstances] <br /> <br>
Location: [Location] <br /> <br>
DateReported: [DateReported] <br /> <br>

InjuryDescription: [InjuryDescription] <br /> <br>
TravelCostsDescription: [TravelCostsDescription] <br /> <br>