Statement of Claim



STATEMENT OF CLAIMDepartment: FORMTEXT ?????Our Claim No.: FORMTEXT ?????Name: FORMTEXT ?????Telephone: FORMTEXT ?????Address: FORMTEXT ?????D/O/B: FORMTEXT ????? FORMTEXT ?????Name of Spouse or Parent if Minor: FORMTEXT ?????Date: FORMTEXT ?????Time: FORMTEXT ?????AM FORMTEXT ?????PMPlace of Accident—Indicate Location By AddressStatement of How Accident Occurred and the Basis of This Claim (Use Additional Sheet if Necessary) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name & Address of Person(s) Present at Time of Accident (Use Additional Sheet if Necessary)1. FORMTEXT ?????Telephone No.: FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ?????Telephone No.: FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ?????Telephone No.: FORMTEXT ????? FORMTEXT ?????Describe Motor Vehicle Owned by You or Member of Household Including License Number (State None if No Listing) FORMTEXT ????? FORMTEXT ?????Name of Insurance Company on the Above Vehicles FORMTEXT ????? FORMTEXT ?????Were you Injured? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, Complete the Following:Describe Injury: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Page 1 of 2List Doctors & Hospital Giving Treatment (Including Complete Name & Address) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Amount of Total Doctor Bill FORMTEXT ?????Hospital Bill FORMTEXT ?????(Itemized Bills Must Be Attached)(Itemized Bill Must Be Attached)Are You Receiving Medical Treatment at Present? FORMCHECKBOX Yes FORMCHECKBOX NoWere You in the Course of Employment? FORMCHECKBOX Yes FORMCHECKBOX NoDid You Lose Income? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, List Employers of Past 3 Years1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of Company or PersonAddressPhone2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????All claim of lost wages must include signed statement from employer itemizing date and pay lost.Date Disability Began FORMTEXT ?????Date Returned to Work FORMTEXT ?????Did you receive damage to motor vehicle or personal property? (List description in detail. Give license number.) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????List Any Other Expense (Nurses, Drugs Must Have Supporting Bills) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do you have any existing claim for workmen’s compensation, personal injury protection, or other claim of personal injury? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list date, place, type of accident, and injury. FORMTEXT ????? FORMTEXT ?????List any accident in which you received any type of injury in the past 5 years, if none, indicate FORMCHECKBOX NONE. (Use back for complete list).Identify Policy Authority Investigating FORMTEXT ?????Their Location FORMTEXT ?????Sworn to and subscribed before meSignedThis ______ day of _______, _______.NOTARY PUBLIC, STATE OF FLORIDA AT LARGEMy Commission Expires: Page 2 of 2 ................
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