Personal Injury Form

Referred by

Today's date

Month

Day

Year

General Information

Full Name

Date of birth

Month

Day

Year

Spouse Full Name

Address

City

State

Home Phone

Work Phone

Description of Incident

Date of incident in question

Month

Day

Year

In your own words, please describe the event in question.

Witnesses

Please list the name, address and phone number of any persons who are, or may be, witnesses, and explain what information you believe each witness may furnish.

Witness name

Witness Phone Number

Witness Address

Witness Information

Add another witness?

Witness Name

Witness Phone Number

Witness Address

Witness Information

Expenses Incurred

Hospital

Total Charge

Date of treatment

Month

Day

Year

Treatment received

Add another expense?

Hospital

Total Charge

Date of treatment

Month

Day

Year

Treatment received

Total Charges

Other expenses

example: ( Personal: $ amount, Nursing: $ amount )

Injury description

Please describe each injury and how it has affected you including things you can no longer do.

Previous claims or lawsuits

Prior claims

If you have made a prior claim or filed suit in regard to a personal injury, including Workers' Compensation Claims, please indicated below where that suit or claim was filed, the attorney or adjusting company handling the claim or lawsuit, date of the injury for which the claim or lawsuit was filed, and what monies were received as a result of that claim or lawsuit. Please describe fully on the lines below.

Employment background

Please indicate what your employment was at the time of your injury, listing the date you began that employment, your employer, exact wages or hourly rate, and the type of work which was performed. Also, list your previous employers for the last 10 years.

Employeer Name

From

Month

Day

Year

Month

Day

Year

Wage

Job duties

Add another employer?

Employeer Name

From

Month

Day

Year

Month

Day

Year

Wage

Job duties

Have you changed employment since the date of your injury?

Currently employed by

Please list the dates of your employment, exact wages and type of work.

Loss of wages or income

If you lost work or income as a result of the injuries in question, please indicate the dates of that lost work, and the amount of dollar loss for the work missed. Please list the dates of work lost regardless of whether you are paid on a sick-leave basis, or have a contract of insurance which would pay as a result of injury. Please indicate gross losses before deduction of income taxes, or other deductions. Example: ( date, employer and dollar loss )

Loss report

Incident Information

Statements

Have you been interviewed by anyone or given a statement concerning this incident? If so, please explain.

Did the police investigate this incident?

Did you talk to the police?

Have any pictures been taken?

Are they available?

Police report

If you have a copy of a police report. Please upload it here.
Files must be less than 2 MB.
Allowed file types: jpg jpeg txt pdf doc docx.

Have you ever been arrested?

Please explain

Has your treatment required a cast, brace or other appliance?

Are you presently keeping an up-to-date summary of your injuries, treatment, and progress?

Previous accidents

Please list any and all previous accidents, injuries or disabilities including any previous complaints or treatment for back or neck pain or pain similar to the injuries in this case.

Do you currently receive disability benefits of any sort?

For what condition?

Property damage

Please list property that has been damaged or lost.

Insurance Information

Your company

Adjuster

P.I.P limits

Liability limits

Uninsured motorists limits

Underinsured motorist limits

Collision limits

Medical limits

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