Free Legal Forms
| Claim for Damage and/or Injury |
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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 |
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