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To: _______________________________________
GENERAL INFORMATION
1. Claimant
(a) Full name: ________________________________________
(b) Address: __________________________________________
City: _________________________ County: _____________
State: _________________ Zip Code: __________________
(c) Age: _______ (d) Marital status: _______________________
2. If claimant is married, name and address of spouse:
__________________________________________________
__________________________________________________
AMOUNT OF CLAIM
3. Amount claimed for property damage: ___________________
4. Amount claimed for personal injury: _____________________
5. Total amount claimed: ________________________________
ACCIDENT RESULTING IN CLAIM
6. Place of accident (include town or city and state; if outside city limits, indicate distance to nearest city or town):
__________________________________________________
7. Date and time of accident: ____________________________
__________________________________________________
(a) Day of week: ________________________________________
(b) Date: _____________________________________________
(c) Time: _____________________________________________
8. Description of accident
(a) Names and addresses of persons involved: ______________
__________________________________________________
(b) Identification of property involved: ______________________
__________________________________________________
(c) Surrounding circumstances: __________________________
__________________________________________________
(d) Cause of accident: __________________________________
__________________________________________________
(e) Other pertinent facts: ________________________________
__________________________________________________
9. Name and addresses of witnesses to accident: ____________
__________________________________________________
PROPERTY DAMAGE AND PERSONAL INJURY
10. Property damage
(a) Description of property damaged: ______________________
__________________________________________________
(b) Present location: ____________________________________
(c) Name and address of owner, if other than claimant: ________
__________________________________________________
(d) Nature of damage: ___________________________________
(e) Extent of damage: ___________________________________
11. Personal injury
(a) Nature of injury: ____________________________________
_________________________________________________
(b) Extent of injury: ____________________________________
_________________________________________________
INSURANCE COVERAGE
12. Collision insurance
(a) Does claimant carry collision insurance? (If yes, answer (b)- (f) below)
______________________
(b) Name and address of insurer: _________________________
__________________________________________________
(c) Policy No.: _________________________________________
(d) Has claimant filed claim against insurer in this instance?
_________________________________________________
(e) If claim has been filed, is coverage for full amount of loss?
_________________________________________________
If not full coverage, amount deductible: ________________
________________________________________________
(f) If claim has been filed, action taken or proposed to be taken by insurer with respect to claim:
_________________________________________________________
13. Public liability and property damage insurance
(a) Does claimant carry public liability and property damage coverage? (If yes, answer (b) below)
_______
(b) Name of insurer: ____________________________________
I declare under the penalty of perjury that the amount of this claim covers only damages and injuries caused by the accident described above. I agree to accept that amount in full satisfaction and final settlement of this claim.
Dated: __________________________
_______________________________________________
Signature
Claim for Damage and/or InjuryReview List
This review list is provided to inform you about this document in question and assist you in its preparation. Use this document to transmit your claim to your insurance agency. Be complete; add any necessary and useful exhibits. The more thorough you are the more apt you are to be believed and get prompt payment.
1. Make multiple copies. Give one set to the insurance agency. Keep a backup set (agencies are notorious for losing or misplacing paperwork). Keep one set with the transaction file.
2. Remember that getting paid on a claim is a sales situation. If they are “sold†on your credibility, they will generally pay promptly. If not sold, it can be a long and ugly process. As we have said before, you have one chance to make a good first impression. Do your homework; get a complete and thorough file together; send it to them promptly. All of this will increase the odds of a satisfactory result in your favor.
What else can I help you with?
How long after an auto accident do you have to file a claim in Kentucky?
What type of claim? Damage or injury?
What does an injury claim solicitor do?
An injury claim solicitor is another name for an injury lawyer. They are lawyers that provide legal representation to those who claim to have been injury.
What is the difference between a Bodily Injury claim and a Liability claim?
A bodily injury claim is a liablity claim. Most auto policys have three (could be many more) liability coverages; Bodily injury (pays for injuries you cause to another), Property damage (pays for damages to property of others), Uninsured motorist coverage (pays for injuries caused by an uninsured motorist). The bodily injury coverage is one coverage under the liability section of your auto policy.
How long does it take to settle claim on elbow injury?
This would certainly depend on the severity of the injury and how long before a physician can diagnose the real damage to the elbow. You would not want to settle the claim before knowing if you will have permanent injuries and to what extent they will be debilitating.
Can you make an auto claim with only basic auto insurance?
If your basic auto insurance just covers bodily injury and property damage then you usually cannot. It is meant to protect you from having to pay out when you damage another partied property or cause them injury.
What is meant by a no win no fee injury claim?
A no win no fee injury claim is when you claim compensation on a injury you had, you don't pay anything if your claim is unsuccessful. Before this, you had to pay legal fees even though you lost in court.
How serious does an injury have to be for an injury claim?
For an injury claim to be made, the injury has to be done on the job and be such that it makes the duties of your job unperformable for any length of time. A doctor is the one that needs to assess the injury and file the claim with the workers compensation company. The assessment will then be made for the injured.
Can you claim bodily injury from your insurance for a car accident in which you were found at fault?
If you had medical coverage, you can.You cannot claim bodily injury against your own policy for yourself because you cannot be liable to yourself. Bodily injury coverage falls under the liability portion of your policy, for injury to others caused by you or the driver of your vehicle. You must carry PIP or MEDPAY for your own injuries.In the UK - the law is based on fault. Namely the driver at fault pays for the injury and vehicle damage to the innocent road user. Motor insurance is compulsory as this pays the liability of the driver at fault. So you cannot claim for bodily injury from your own insurance as you would be claiming against yourself - but if your motor policy was comprehensive you can claim from your own insurer for vehicle damage - subject to an excess. See the related link entitled "car driver injury claims" for a full explanation as to when a car driver can claim and when a car driver is considered liable.
Does playing a video game console on an HD television reduce the life expectancy of it andor damage it?
No.
How do you get started with your injury claim?
To get started with an injury claim it is good to find a lawyer first. Many lawyers specialize in injury claims and would be delighted to have your business.
Can someone claim a whiplash injury?
Yes, you can. You should get in contact with the insurance agency of the other person involved and claim your injury. It requires a proof of injury from a doctor.
What is the standard policy for minors who are passengers in auto accidents and who gets the claim?
Anyone who suffers injury or property damage in a collision is allowed to file a claim to insurance companies. Damages are to be paid by the insurance company of the person deemed to be at fault. In the case of injury to minors, damages are to be paid to the parents or guardians.
