Personal Injury Form

General Information
Description of Incident
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.
Expenses Incurred
example: ( Personal: $ amount, Nursing: $ amount )
Injury description
Previous claims or lawsuits
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.
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 )
Incident Information
Have you been interviewed by anyone or given a statement concerning this incident? If so, please explain.
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.
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.
Property damage
Insurance Information
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