PERSONAL INJURY INTAKE (Please use additional paper if there is insufficient space for any section)

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "PERSONAL INJURY INTAKE (Please use additional paper if there is insufficient space for any section)"

Transcription

1 PERSONAL INJURY INTAKE (Please use additional paper if there is insufficient space for any section) I. YOUR GENERAL INFORMATION Last Name: First Name: MI: Date of Birth: SSN: Street City/State/Zip: Home Work Cell Spouse: Date of Birth: SSN: Child: Child: Child: DOB: DOB: DOB: II. YOUR EMPLOYMENT INFORMATION Employer: Occupation: Weekly/Biweekly Salary: $ No. of Hours Worked Per Day: Supervisor: Date Employment Commenced: No. of Days Worked Per Week: Phone No.: Last Day Worked Before Accident: Date Returned: Light/Restricted Duty? 1

2 How Long Were You Confined to Bed? How Long Were You Confined Home? III. YOUR INSURANCE INFORMATION A. Do you or your spouse have health and/or disability insurance through your employment? _ If your answer is yes, then provide the following information: Name and address of health insurance company through employment: Employer health insurance company s policy no.: Has health insurance through employment paid any benefits for this accident? If your previous answer is yes, approximately how much? Name and address of disability insurance company through employment: Employer disability insurance company s policy no.: Has disability insurance through employment paid any benefits for this accident? If your previous answer is yes, approximately how much? B. Do you have private (not through employment) health or disability insurance? If your answer is yes, please provide the following information: Name and address of private health insurance company: Private health insurance company s policy no.: Has your private health insurance paid any benefits for this accident? If your previous answer is yes, approximately how much? Name and address of private disability insurance company: 2

3 Priviate disability insurance company s policy no.: Has your private disability insurance paid any benefits for this accident? _ If your previous answer is yes, approximately how much? IV. YOUR EDUCATION High School Name: Graduation Date: Post High School Name: Degree(s) obtained and Date: V. ACCIDENT INFORMATION Date of Accident: Day: Time: Location of Accident: Was a public governmental authority, agency, or employee possibly at fault? Yes No If yes, state whom and why you believe they may be at fault: _ What is the address or the intersection where the accident occurred? 3

4 You Were Traveling on What Street/Road? Offending Vehicle Was Traveling on What Street/Road? Weather: Your Position in Vehicle: Describe the accident: Law Enforcement Dept(s). at scene: Officer(s) name(s): Was there emergency care at scene? Yes No If your answer is yes, who/what provided emergency care? Were you transported in an ambulance? Yes No If your answer is yes, what is the name of the ambulance service? Was there fire or other rescue care at scene? Yes No If your answer is yes, which fire or rescue service? 4

5 VI. PLEASE DRAW A DIAGRAM OF THE ACCIDENT BELOW: VII. WITNESSES TO ACCIDENT Witness #1: Name: Phone Number: Witness #2: Name: Phone Number: Witness #3: Name: Phone Number: 5

6 VIII. VEHICLE INFORMATION (if applicable) You were the in Vehicle #1 (Owner/Operator/Passenger) You were a pedestrian. Vehicle No. 1 (Your Vehicle): Vehicle Plate No.: Vehicle s Make: Vehicle s Year: Vehicle s Model: Vehicle s VIN: Owner s Name: Owner s Leaseholder s Name: Leaseholder s Operator: Insurance Co.: Policy Holder: Effective Date of Policy: Policy No.: Expiration Date of Policy: Vehicle No. 2 (other party s vehicle): Vehicle Plate No.: Vehicle s Make: Vehicle s Year: Vehicle s Model: Vehicle s VIN: Owner s Name: Owner s 6

7 Leaseholder s Name: Leaseholder s Operator: Insurance Co.: Policy Holder: Effective Date of Policy: Policy No.: Expiration Date of Policy: Vehicle No. 3 (other party s vehicle): Vehicle Plate No.: Vehicle s Make: Vehicle s Year: Vehicle s Model: Vehicle s VIN: Owner s Name: Owner s Leaseholder s Name: Leaseholder s Operator: Insurance Co.: Policy Holder: Effective Date of Policy: Policy No.: Expiration Date of Policy: 7

8 IX. IF NOT ALREADY LISTED ABOVE, PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT ANY PARTY THAT YOU BELIEVE MAY BE AT FAULT: AT FAULT PARTY #1: Name: Phone Number: Why do you believe they may be at fault? _ Their liability insurance company: The address of their liability insurance company: Liability policy holder: Policy no.: Effective date of policy: Expiration date of policy: AT FAULT PARTY #2: Name: Phone Number: Why do you believe they may be at fault? _ Their liability insurance company: The address of their liability insurance company: Liability policy holder: Policy no.: Effective date of policy: Expiration date of policy: 8

9 X. HOSPITALS/CLINICS WHERE YOU HAVE TREATED FOR INJURIES FROM ACCIDENT Hospital/Clinic #1: Dates of Treatment: Date of Discharge: Treatment Type: ER Admission Outpatient Clinic Visit Hospital/Clinic #2: Dates of Treatment: Date of Discharge: Treatment Type: ER Admission Outpatient Clinic Visit Hospital/Clinic #3: Dates of Treatment: Date of Discharge: Treatment Type: ER Admission Outpatient Clinic Visit Hospital/Clinic #4: Dates of Treatment: Date of Discharge: Treatment Type: ER Admission Outpatient Clinic Visit 9

10 XI. PHYSICIANS THAT YOU HAVE SEEN FOR INJURIES FROM ACCIDENT 1. Doctor s Name: Specialty: 2. Doctor s Name: Specialty: 3. Doctor s Name: Specialty: 4. Doctor s Name: Specialty: XII. ANY PREVIOUS ACCIDENTS? Have you ever been involved in a previous automobile or any other type of accident? Yes No If yes, complete the following: Date: Place: Description: 10

11 Injuries Sustained: List the medical providers who rendered treatment for injuries from prior accident: Did you commence a claim or a lawsuit? Yes No If Yes, Please list the name and address of your prior attorney: XIII. OTHER MEDICAL HISTORY List past physicians of note and current primary or treating physicians below. 1. Doctor s Name: Specialty: Description of Condition(s) You Are or Have Treated for With This Doctor/Provider: 2. Doctor s Name: Specialty: 11

12 Description of Condition(s) You Are or Have Treated for With This Doctor/Provider: 3. Doctor s Name: Specialty: Description of Condition(s) You Are or Have Treated for With This Doctor/Provider: 4. Doctor s Name: Specialty: Description of Condition(s) You Are or Have Treated for With This Doctor/Provider: Do you have any medical conditions or disabilities that pre-date the accident? Yes No If yes, complete the following: What: Date(s): Description of How Sufferred: 12

13 Symptoms/Limitations: List the medical providers who rendered treatment for injuries or symptoms: Do you still suffer from the condition/disability? Yes No If no, when did condition/disability end? Date: Signature 13

THOMPSON, THOMPSON & GLANVILLE, PLC PERSONAL INJURY INITIAL CLIENT INTERVIEW (AUTO) BACKGROUND INFORMATION

THOMPSON, THOMPSON & GLANVILLE, PLC PERSONAL INJURY INITIAL CLIENT INTERVIEW (AUTO) BACKGROUND INFORMATION THOMPSON, THOMPSON & GLANVILLE, PLC PERSONAL INJURY INITIAL CLIENT INTERVIEW (AUTO) Date: Referral Source: Atty: Legal Asst.: Office: BACKGROUND INFORMATION Full Name: First Middle Last Other names known

More information

EVEREST INSURANCE COMPANY OF CANADA ACCIDENT CLAIM FORM INSTRUCTIONS

EVEREST INSURANCE COMPANY OF CANADA ACCIDENT CLAIM FORM INSTRUCTIONS ACCIDENT CLAIM FORM INSTRUCTIONS Everest Insurance Company of Canada must receive your completed claim forms within thirty (30) days of the accident occurring. Complete the attached Sport Accident Claims

More information

CLIENT INTERVIEW FORM AUTO ACCIDENTS

CLIENT INTERVIEW FORM AUTO ACCIDENTS CLIENT INTERVIEW FORM AUTO ACCIDENTS Please fill out the following form to the best of your ability. YOUR INFORMATION First Name: MI: Last Name: Drivers License #: Date of Birth: Email Phone (work): State:

More information

INITIAL CLIENT STATEMENT

INITIAL CLIENT STATEMENT PERSONAL INJURY/AUTO ACCIDENT INTAKE SHEET SOL: INITIAL CLIENT STATEMENT HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE? IF SO, PLEASE GIVE NAME OF ATTORNEY: DO YOU HAVE A SIGNED RELEASE BY THAT ATTORNEY?

More information

ACCIDENT, INJURY, AND INCIDENT REPORTING PROCEDURES

ACCIDENT, INJURY, AND INCIDENT REPORTING PROCEDURES ACCIDENT, INJURY, AND INCIDENT REPORTING PROCEDURES VEHICLE ACCIDENTS/PROPERTY DAMAGE Non-Workers Compensation Accident Report Form Attached is a sample copy of the accident report for vehicle damage,

More information

PERSONAL INJURY/AUTO ACCIDENT QUESTIONNAIRE

PERSONAL INJURY/AUTO ACCIDENT QUESTIONNAIRE PERSONAL INJURY/AUTO ACCIDENT QUESTIONNAIRE TODAY S DATE: PERSONAL INFORMATION: NAME: (home) (cell) Age: Date of Birth: Social Security No: EMPLOYER: (work) Occupation: Worked there how long? Immediate

More information

THOMPSON, THOMPSON & GLANVILLE, PLC PERSONAL INJURY CLIENT INTERVIEW FORM BACKGROUND INFORMATION

THOMPSON, THOMPSON & GLANVILLE, PLC PERSONAL INJURY CLIENT INTERVIEW FORM BACKGROUND INFORMATION THOMPSON, THOMPSON & GLANVILLE, PLC PERSONAL INJURY CLIENT INTERVIEW FORM Date: Referral Source: Atty: Legal Asst.: Office: BACKGROUND INFORMATION Full Name: First Middle Last Other names known by (including

More information

HAROLD CAMPING i ii iii iv v vi vii viii ix x xi xii 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

More information

Notice of Claim. Last First Middle Area Code/ Telephone Number. Last First Middle Area Code/ Telephone Number

Notice of Claim. Last First Middle Area Code/ Telephone Number. Last First Middle Area Code/ Telephone Number Claimant: Notice of Claim Last First Middle Area Code/ Telephone Number Street Address Additional Address City State Zip Date of Birth Social Security Number If Notices and correspondence in connection

More information

HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE? WHO WERE YOU REFERRED BY: (INDIVIDUAL, YELLOW PAGE AD, ETC...) Email Address:

HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE? WHO WERE YOU REFERRED BY: (INDIVIDUAL, YELLOW PAGE AD, ETC...) Email Address: PERSONAL INJURY/AUTO ACCIDENT INTAKE SHEET SOL: INITIAL CLIENT STATEMENT TODAY S DATE: HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE? IF SO, PLEASE GIVE NAME OF ATTORNEY : DO YOU HAVE A SIGNED RELEASE

More information

INCIDENT INFORMATION SHEET. Driver or Passenger? (please circle)

INCIDENT INFORMATION SHEET. Driver or Passenger? (please circle) INCIDENT INFORMATION SHEET CLIENT INFORMATION Date Client Name: Driver or Passenger? (please circle) Spouse s full name, if married: Home # Work # Cell # E-Mail at home E-Mail at work Date of Birth Social

More information

CLIENT QUESTIONNAIRE FOR PERSONAL INJURY/ WORKER S COMPENSATION CLAIMS

CLIENT QUESTIONNAIRE FOR PERSONAL INJURY/ WORKER S COMPENSATION CLAIMS By Appointment Only: 1641 N. Milwaukee Avenue Libertyville, IL 60048 (847) 549-9102 Email: ted@bondpc.com http://www.tedbondjrpc.com CLIENT QUESTIONNAIRE FOR PERSONAL INJURY/ WORKER S COMPENSATION CLAIMS

More information

Revision Date: Title: REPORTING PROPERTY DAMAGE AND PERSONAL INJURIES Page 1 of 2. Approved By: President, MABAS Div. III Date

Revision Date: Title: REPORTING PROPERTY DAMAGE AND PERSONAL INJURIES Page 1 of 2. Approved By: President, MABAS Div. III Date No. Subject: RECORDS AND REPORTS Creation 1/1/08 Revision Title: REPORTING PROPERTY DAMAGE AND PERSONAL INJURIES Page 1 of 2 I. Scope Approved By: President, MABAS Div. III Date This directive was promulgated

More information

Claim Form. Journey Report Form. To be completed by Policyholder

Claim Form. Journey Report Form. To be completed by Policyholder This form must be accompanied by an Attending Physicians Statement, which can be obtained by telephoning any of our offices listed. By furnishing this Form the Company makes no admission of Liability or

More information

THE SALAZAR LAW FIRM, P.A. NEW CLIENT INFORMATION SHEET (PERSONAL INJURY MOTOR VEHICLE) PERSONAL INFORMATION:

THE SALAZAR LAW FIRM, P.A. NEW CLIENT INFORMATION SHEET (PERSONAL INJURY MOTOR VEHICLE) PERSONAL INFORMATION: THE SALAZAR LAW FIRM, P.A. NEW CLIENT INFORMATION SHEET (PERSONAL INJURY MOTOR VEHICLE) TODAY'S DATE PERSONAL INFORMATION: DATE OF ACCIDENT NAME HOME ADDRESS CITY STATE ZIP HOME TELEPHONE ( ) DATE OF BIRTH

More information

Schneps, Leila; Colmez, Coralie. Math on Trial : How Numbers Get Used and Abused in the Courtroom. New York, NY, USA: Basic Books, 2013. p i.

Schneps, Leila; Colmez, Coralie. Math on Trial : How Numbers Get Used and Abused in the Courtroom. New York, NY, USA: Basic Books, 2013. p i. New York, NY, USA: Basic Books, 2013. p i. http://site.ebrary.com/lib/mcgill/doc?id=10665296&ppg=2 New York, NY, USA: Basic Books, 2013. p ii. http://site.ebrary.com/lib/mcgill/doc?id=10665296&ppg=3 New

More information

GROUP TOTAL & PERMANENT DISABILITY CLAIM FORM

GROUP TOTAL & PERMANENT DISABILITY CLAIM FORM GROUP TOTAL & PERMANENT DISABILITY CLAIM FORM A Member of the OCBC Group CLAIM SUBMISSION PROCEDURES Please read carefully before you complete the attached Claim Form. 1. 2. The Great Eastern Life Assurance

More information

How did you hear about The Mills Law Firm? MVA Premises Liability Labor Law Product Liability Other:

How did you hear about The Mills Law Firm? MVA Premises Liability Labor Law Product Liability Other: CLIENT QUESTIONNAIRE Name: Date: How did you hear about The Mills Law Firm? Type of Case: MVA Premises Liability Labor Law Product Liability Other: Please answer the following questions with as much detail

More information

GENERAL BACKGROUND INFORMATION

GENERAL BACKGROUND INFORMATION Internal Office Use Staff member initials for interview: Date of Incident : Statute of Limitations: Potential Defendants: CLIENT INTAKE FORM Please take the time to answer the questions below as accurately

More information

Inquiry form - Motor Accident Page 1

Inquiry form - Motor Accident Page 1 Inquiry form - Motor Accident Page 1 1. Personal Details i. Full name Date of Birth i Residential address Documents to bring If relevant in your situation : diagram or photo of accident site, police report

More information

PERSONAL INJURY INTAKE SHEET INITIAL CLIENT STATEMENT HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE?

PERSONAL INJURY INTAKE SHEET INITIAL CLIENT STATEMENT HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE? PERSONAL INJURY INTAKE SHEET INITIAL CLIENT STATEMENT HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE? IF SO, PLEASE GIVE NAME OF ATTORNEY: DO YOU HAVE A SIGNED RELEASE BY THAT ATTORNEY? SOL: DATE

More information

LOYAL AMERICAN LIFE INSURANCE COMPANY PO BOX 1604, DUNCAN, OKLAHOMA, 73534-1604 Phone (800) 366-8354

LOYAL AMERICAN LIFE INSURANCE COMPANY PO BOX 1604, DUNCAN, OKLAHOMA, 73534-1604 Phone (800) 366-8354 INSTRUCTIONS FOR FILING AN ACCIDENT CLAIM The forms must be completed by the claimant. If the claimant is a minor, the primary insured parent must complete the forms. All questions on the forms must be

More information

Applicant Name: Date: / / Uniform Size: Pants: Waist: / Length: Shirt: Jacket: Cell Phone No. : ( ) -

Applicant Name: Date: / / Uniform Size: Pants: Waist: / Length: Shirt: Jacket: Cell Phone No. : ( ) - Attention: Human Resources, Close Range International, Inc. From: Security Manager Fax Number: 323.342.0359 Applicant Name: Date: / / Uniform Size: Pants: Waist: / Length: Shirt: Jacket: Cell Phone No.

More information

POTENTIAL CLIENT INTAKE SHEET - PREMISES LIABILITY IMPORTANT

POTENTIAL CLIENT INTAKE SHEET - PREMISES LIABILITY IMPORTANT POTENTIAL CLIENT INTAKE SHEET - PREMISES LIABILITY Date: Lawyer: Date of Accident: I. CLIENT INFORMATION Client Name: First Middle Last Date of Birth: You would be preferred to be called (nickname): If

More information

INSTRUCTIONS FOR USE

INSTRUCTIONS FOR USE Uniform Personal Injury Interrogatories INSTRUCTIONS FOR USE A. All information is to be divulged which is in the possession of the individual or corporate party, his attorneys, investigator, agents, employees,

More information

Tort Claim Form PLEASE CHECK THE FOLLOWING TO MAKE SURE ALL PERTINENT INFORMATION IS GIVEN BEFORE SUBMITTING YOUR CLAIM.

Tort Claim Form PLEASE CHECK THE FOLLOWING TO MAKE SURE ALL PERTINENT INFORMATION IS GIVEN BEFORE SUBMITTING YOUR CLAIM. Tort Claim Form If you have suffered an injury or damage to your property that you believe is the result of the negligence or actions of Rowan University or of individual(s) acting in the capacity of employee(s)

More information

POTENTIAL CLIENT INTAKE SHEET - AUTO ACCIDENT IMPORTANT

POTENTIAL CLIENT INTAKE SHEET - AUTO ACCIDENT IMPORTANT POTENTIAL CLIENT INTAKE SHEET - AUTO ACCIDENT Date: Lawyer: Date of Accident: I. CLIENT INFORMATION Client Name: First Middle Last Date of Birth: You would be preferred to be called (nickname): Gender:

More information

Attending Physician Statement

Attending Physician Statement Attending Physician Statement (Hospitalisation/ Accident/ Total & Permanent Disability Claim) Important tes 1. This form is to be completed by the life insured s (Patient s) doctor. 2. To enable us to

More information

INDIVIDUAL HOSPITAL & SURGICAL CLAIM FORM

INDIVIDUAL HOSPITAL & SURGICAL CLAIM FORM INDIVIDUAL HOSPITAL & SURGICAL CLAIM FORM Dear claimant, We are sorry to learn about your hospitalization. In order for us to process your claim, we require the following: (1) Claimant s Statement (2)

More information

STANDARD OPERATING GUIDELINE

STANDARD OPERATING GUIDELINE STANDARD OPERATING GUIDELINE ADMINISTRATION INJURY ACCIDENT REPORTING (POLICY & FORMS A-F) EFFECTIVE: 11/26/2011 REVISED: S.O.G #: 150 PAGE: 1 OF 3 1.0 Objective 1.1 To establish and maintain a system

More information

MEDICAL MAL-PRACTICE INTAKE SHEET INITIAL CLIENT STATEMENT. Cell Number: Email Address:

MEDICAL MAL-PRACTICE INTAKE SHEET INITIAL CLIENT STATEMENT. Cell Number: Email Address: MEDICAL MAL-PRACTICE INTAKE SHEET INITIAL CLIENT STATEMENT SOL: DATE OF ACCIDENT/LOSS: PERSONAL INFORMATION: NAME: (home) Cell Number: Age: Date of Birth: Social Security No: Email EMPLOYER: (work) Occupation:

More information

IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI., ) ) Plaintiff, ) ) Cause No. vs. ) ) Division No., ) ) Defendant.

IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI., ) ) Plaintiff, ) ) Cause No. vs. ) ) Division No., ) ) Defendant. IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI, ) ) Plaintiff, ) ) Cause No. vs. ) ) Division No., ) ) Defendant. ) DEFENDANT S INTERROGATORIES DIRECTED TO PLAINTIFF COMES NOT defendant,

More information

INDIVIDUAL TOTAL & PERMANENT DISABILITY (TPD) CLAIM FORM

INDIVIDUAL TOTAL & PERMANENT DISABILITY (TPD) CLAIM FORM INDIVIDUAL TOTAL & PERMANENT DISABILITY (TPD) CLAIM FORM Dear claimant, We are sorry to learn about your disability. In order for us to process your claim, we require the following: (1) Claimant s Statement

More information

NEW YORK STATE BAR ASSOCIATION. LEGALEase. If You Have An Auto Accident SAMPLE

NEW YORK STATE BAR ASSOCIATION. LEGALEase. If You Have An Auto Accident SAMPLE NEW YORK STATE BAR ASSOCIATION LEGALEase If You Have An Auto Accident If You Have An Auto Accident What should you do if you re involved in an automobile accident in New York? STOP! By law, you are required

More information

Accident/Illness Claim

Accident/Illness Claim QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections

More information

Claim Form Road Accident Family Protection Plan (Injury cover)

Claim Form Road Accident Family Protection Plan (Injury cover) Claim Form Road Accident Family Protection Plan (Injury cover) Return address and Zestlife contact details: E-mail: info@zestlife.co.za or fax: 021 001 0248 or post to Private Bag X1005, Claremont, 7735

More information

VEHICLE ACCIDENT REPORTING KIT

VEHICLE ACCIDENT REPORTING KIT VEHICLE ACCIDENT REPORTING KIT SAFE DRIVING IS A FULL TIME JOB! REPORT ANY INCIDENT / ACCIDENT WITHIN 24 HOURS TO: GLATFELTER CLAIMS MANAGEMENT, INC. 10100 Trinity Parkway, Suite 110 P.O. Box 7187 Stockton,

More information

Accident/Illness Claim

Accident/Illness Claim QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections.

More information

Total and Permanent Disability claim form

Total and Permanent Disability claim form Total and Permanent Disability claim form 1. Notice Of Claim Written notice of claim must be given to AXA Life within 90 days from the date of disability certified by a specialist in the relevant field.

More information

Phone (910) Fax (910) APPLICATION FOR EMPLOYMENT

Phone (910) Fax (910) APPLICATION FOR EMPLOYMENT Phone (910)483-4449 Fax (910)483-2905 APPLICATION FOR EMPLOYMENT DATE Name Last First Middle Maiden Present address Number Street City State Zip Home Phone ( ) Cell Phone ( ) E-mail address: Are you at

More information

Schneps, Leila; Colmez, Coralie. Math on Trial : How Numbers Get Used and Abused in the Courtroom. New York, NY, USA: Basic Books, p i.

Schneps, Leila; Colmez, Coralie. Math on Trial : How Numbers Get Used and Abused in the Courtroom. New York, NY, USA: Basic Books, p i. New York, NY, USA: Basic Books, 2013. p i. http://site.ebrary.com/lib/mcgill/doc?id=10665296&ppg=2 New York, NY, USA: Basic Books, 2013. p iii. http://site.ebrary.com/lib/mcgill/doc?id=10665296&ppg=4 New

More information

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au

More information

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER NEW YORK MOTOR VEHICLE -FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE -FAULT BENEFITS NAME AND ADDRESS OF INSURER * NAME, ADDRESS, AND PHONE NUMBER OF INSURER S CLAIMS REPRESENTATIVE* POLICYHOLDER

More information

Workers Compensation Claims Reporting. What do I do after a Workers Compensation accident occurs?

Workers Compensation Claims Reporting. What do I do after a Workers Compensation accident occurs? Workers Compensation Claims Reporting What do I do after a Workers Compensation accident occurs? Secure medical treatment for your injured employee. If during normal business hours, use an Occupational

More information

PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE:

PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE: PATIENT INFORMATION LAST FIRST MI GENDER M F BIRTHDATE MO./ DAY/ YEAR SS# - - ADDRESS CITY ST ZIP PHONE (CELL) PHONE (HOME) EMAIL MARITAL STATUS EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT WHO IS YOUR PRIMARY

More information

Once we have received all the above required documents, we will process your claim and inform you of the outcome as soon as possible.

Once we have received all the above required documents, we will process your claim and inform you of the outcome as soon as possible. ACCIDENT CLAIM FORM Dear Claimant, We are sorry to learn of your accident. In order for us to process your claim, we require the following: 1) Claimant s Statement. 2) 1 Clinical Abstract Application Form.

More information

ACCIDENTAL INJURY CLAIM FORM

ACCIDENTAL INJURY CLAIM FORM ACCIDENTAL INJURY CLAIM FORM Failure to complete this form in its entirety may result in a delay in processing this claim. FILING CLAIM FOR: Accidental Injury Only Injury With Disability Injury With Hospitalization

More information

Creditor Disability Claim Application Kit

Creditor Disability Claim Application Kit Life and Health Claims Dept. Creditor Disability Claim Application Kit The Application Kit contains: an instruction sheet plus forms that need to be completed in order to apply for disability benefits;

More information

FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COURT TERM: NO.

FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COURT TERM: NO. FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA PLAINTIFF(S) v. DEFENDANT(S) CIVIL TRIAL DIVISION Compulsory Arbitration Program COURT TERM: NO. Defendant s Interrogatories

More information

Motor Vehicle Claim Form

Motor Vehicle Claim Form Motor Vehicle Claim Form MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring

More information

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au

More information

INVESTIGATIONS. Page 1

INVESTIGATIONS. Page 1 INVESTIGATIONS Page 1 SECTION 9 INVESTIGATIONS INVESTIGATION POLICY Investigation Policy - Sample 1...4 Investigation Policy - Sample 2...5 INVESTIGATION FORMS Incident Investigation Report - Sample 1...7

More information

Spokane County Accident Prevention Program

Spokane County Accident Prevention Program Spokane County Accident Prevention Program 1.7 ACCIDENT REPORTING POLICY I. SCOPE Policy No. 1.7 Revised: August 2007 Reporting accidents/incidents that result in an injury to a Spokane County employee,

More information

Defendant s Interrogatories Addressed To Plaintiff Premises Liability Cases

Defendant s Interrogatories Addressed To Plaintiff Premises Liability Cases FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY PLAINTIFF S NAME : Civil Trial Division : : Compulsory Arbitration Program : vs. : : Term, 20 : DEFENDANT S NAME

More information

Accident/Illness Claim

Accident/Illness Claim QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections.

More information

ACCIDENTAL INJURY CLAIM FORM

ACCIDENTAL INJURY CLAIM FORM ACCIDENTAL INJURY CLAIM FORM Failure to complete this form in its entirety may result in a delay in processing this claim. FILING CLAIM FOR (check all that apply): Accidental Injury Only Injury With Disability

More information

FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA NO.

FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA NO. FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA PLAINTIFF(S) v. DEFENDANT(S) CIVIL TRIAL DIVISION Compulsory Arbitration Program COURT TERM: NO. Plaintiff(s) Interrogatories

More information

Office of Graduate Medical Education Salary and Benefits Information

Office of Graduate Medical Education Salary and Benefits Information Office of Graduate Medical Education Salary and Benefits Information Salary levels for 2009-2010 will be determined as part of the FY2010 budget process and will be available approximately May or June

More information

Notice of Accident Claim Form

Notice of Accident Claim Form Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Notice of Accident Claim Form (Non-Fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident

More information

PERSONAL INJURY PARTICULARS

PERSONAL INJURY PARTICULARS PERSONAL INJURY PARTICULARS Magistrates Court of South Australia (Civil Division) www.courts.sa.gov.au Date Filed: Court Use Form 22 Trial Court Action No Address Street Telephone Facsimile DX BETWEEN

More information

Personal Injury Questionnaire

Personal Injury Questionnaire Personal Injury Questionnaire Answer each question fully and accurately. Success in this case depends on mutual confidence and complete cooperation between you (as the client) and the attorney. It is imperative

More information

NTUC Gift Total and Permanent Disability Claim Form

NTUC Gift Total and Permanent Disability Claim Form NTUC Gift Total and Permanent Disability Claim Form Dear Claimant We are sorry to learn of your injury. In order for us to process your claim, please complete this form in FULL and attach the required

More information

WORK INJURY BENEFIT CLAIM FORM

WORK INJURY BENEFIT CLAIM FORM WORK INJURY BENEFIT CLAIM FORM Important information please read carefully i. This report is to be completed by the employer in case of injury to or death of a workman and returned back along with the

More information

Great-West G R O U P. Short Term Disability Income Benefits Employee s Statement

Great-West G R O U P. Short Term Disability Income Benefits Employee s Statement Great-West G R O U P Short Term Disability Income Benefits Employee s Statement Employee s Statement Short Term Disability Income Benefits This guide contains the forms you need to apply for disability

More information

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au

More information

Notice of Accident Claim Form

Notice of Accident Claim Form Insurer's Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) tice of Accident Claim Form (n-fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident Insurance

More information

CLIENT QUESTIONNAIRE AUTO INJURY PERSONAL

CLIENT QUESTIONNAIRE AUTO INJURY PERSONAL CLIENT QUESTIONNAIRE AUTO INJURY PERSONAL 1. Full Name: 2. Other Names Known By: 3. Address: 4. Home Phone: Work Phone: 5. Date of Birth: Age: 6. Social Security Number: 7. Marital Status: 8. Spouse (including

More information

Notice of Accident Claim Form

Notice of Accident Claim Form Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Notice of Accident Claim Form (Fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident Insurance

More information

Personal Accident or Sickness Claim

Personal Accident or Sickness Claim INSURANCE BROKERS 22 Welsford Street, Shepparton PO Box 1377, Shepparton VIC 3632 www.ggib.com.au Phone (03) 5821-7777 Fax (03) 5822-2916 Email ggib@ggib.com.au ABN 52 858 454 162 AFS 237 533 Personal

More information

Personal Accident Claim Form

Personal Accident Claim Form Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Personal Accident Claim Form

More information

Application for Scheduled Benefits

Application for Scheduled Benefits Application for Scheduled Benefits CLAIM FORM B To be completed by, or on behalf of, an injured driver/ passenger/motorcyclist/pillion passenger/pedestrian/cyclist Please also complete Claim Form A Notice

More information

ACCIDENTAL INJURY CLAIM FORM

ACCIDENTAL INJURY CLAIM FORM ACCIDENTAL INJURY CLAIM FORM Failure to complete this form in its entirety may result in a delay in processing this claim. FILING CLAIM FOR (check all that apply): Accidental Injury Only Injury With Disability

More information

APPLICATION FOR EMPLOYMENT *Applicant must complete in his or her own handwriting

APPLICATION FOR EMPLOYMENT *Applicant must complete in his or her own handwriting APPLICATION FOR EMPLOYMENT *Applicant must complete in his or her own handwriting Date of Application / / Social Security Number / / Applicant Name Address City _ State Zip Home Phone Cell Phone How long

More information

Step 2: Verify that the location of the accident is safe and secure. Protect the site as necessary.

Step 2: Verify that the location of the accident is safe and secure. Protect the site as necessary. Supervisor's Guide to Managing On-the-Job Injuries Employee Responsibilities: Employee reports injury to employer/supervisor and seeks treatment from a BWC-certified medical provider (All providers in

More information

CLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle

CLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle Notice of Accident CLAIM FORM A To be completed by the registered operator/ owner or driver of the vehicle If you have suffered Personal Injury resulting directly from this motor accident and wish to claim

More information

Instructions for Disability Insurance Claim

Instructions for Disability Insurance Claim Instructions for Disability Insurance Claim Instructions for Claimant 1. Please complete the Claimant's Statement for Group Creditor Disability Insurance. Besuretosign and date all entries. Include your

More information

DELAWARE COUNTY. Supersedes June 15, 1988, March 22, 1999

DELAWARE COUNTY. Supersedes June 15, 1988, March 22, 1999 DELAWARE COUNTY Subject Self- Program Effective June 28, 2004 Supersedes June 15, 1988, March 22, 1999 This Sheet 1 Total 5 Purpose To provide a written document explaining the Self- Program, preferred

More information

Utah Transit Authority Personal Injury Protection Information Revised 2/3/10

Utah Transit Authority Personal Injury Protection Information Revised 2/3/10 Utah Transit Authority Personal Injury Protection Information Revised 2/3/10 A passenger on a UTA bus or a pedestrian injured by a bus may be entitled to Personal Injury Protection benefits. To claim any

More information

Defendant s Interrogatories Addressed to Plaintiff(s) Motor Vehicle Liability Cases

Defendant s Interrogatories Addressed to Plaintiff(s) Motor Vehicle Liability Cases FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY PLAINTIFF S NAME : Civil Trial Division : : Compulsory Arbitration Program : vs. : : Term, 20 : DEFENDANT S NAME

More information

Workers' Compensation

Workers' Compensation Workers' Compensation Accident Reporting Procedures LISD FORMS AVAILABLE AT THE SAFETY WEBSITE ARE IN BOLD LETTERS 1. Employee reports accident or near miss to campus/department Safety Officer. The Safety

More information

NOVA Pain & Rehab Center Accident Forms. Patient Information

NOVA Pain & Rehab Center Accident Forms. Patient Information NOVA Pain & Rehab Center Accident Forms Patient Information Please provide all information requested. If you have any questions or need help, please call the office (703-535-8887) or see one of the staff

More information

Please print out for signatures and post original to AIG, PO Box 1745, Shortland Street, Auckland 1140

Please print out for signatures and post original to AIG, PO Box 1745, Shortland Street, Auckland 1140 Accident Insurance Claim Form Please print out for signatures and post original to AIG, PO Box 1745, Shortland Street, Auckland 1140 Employer /Group / Bank group: Full policy Number with Prefix : Full

More information

Motor Accident Notification Form

Motor Accident Notification Form Motor Accident tification Form This form is Approved Form AF2014-59, approved on 26 August 2014 by Karen Doran, delegate of the director-general, under section 276 of the Road Transport (Third- Party Insurance)

More information

Personal Accident and Sickness Claim Form

Personal Accident and Sickness Claim Form Please return claim form to: Corporate Services Network 2 / 280 George Street Sydney NSW 2000 Ph: +61 2 8256 1770 Fax: +61 2 8256 1775 E-mail: claims@csnet.com.au Employer: Claimants Name: Job Title: Work

More information

Domestic Accident & Health Division 80 Pine Street, 13 th Floor New York, NY 10005

Domestic Accident & Health Division 80 Pine Street, 13 th Floor New York, NY 10005 Domestic Accident & Health Division 80 Pine Street, 13 th Floor New York, NY 10005 Welcome to the AIG Companies family of customers. We appreciate that you had a choice when placing your insurance and

More information

MONTGOMERY YMCA APPLICATION FOR EMPLOYMENT

MONTGOMERY YMCA APPLICATION FOR EMPLOYMENT RETURN TO BRANCH: MONTGOMERY YMCA APPLICATION FOR EMPLOYMENT YMCA Mission To put Christian principles into practice through programs that build a healthy body, mind and spirit for all. Equal Opportunity

More information

CLAIM FORM AND BODILY INJURY/WRONGFUL DEATH CLAIM QUESTIONNAIRE

CLAIM FORM AND BODILY INJURY/WRONGFUL DEATH CLAIM QUESTIONNAIRE CLAIM FORM AND BODILY INJURY/WRONGFUL DEATH CLAIM QUESTIONNAIRE Claimant s Name: Address: City/State: Attorney s Name: Firm: Address: Phone: City/State Phone: * Should you require additional space in responding

More information

Workers Compensation Policy and Procedure

Workers Compensation Policy and Procedure EL PASO COUNTY DEPARTMENT OF HUMAN RESOURCES Workers Compensation Policy and Procedure Revised Date: March 21, 2016 I. Purpose The County of El Paso provides workers compensation benefits for incidental

More information

Group Income Protection Insurance Claim form to be completed by the Employee

Group Income Protection Insurance Claim form to be completed by the Employee Group Income Protection Insurance Claim form to be completed by the Employee Please complete and return this claim form in the pre-paid envelope provided as soon as is possible. Please answer all questions

More information

IN THE CIRCUIT COURT OF GREENE COUNTY STATE OF MISSOURI., ) Plaintiff, ) Case No. v. ) ), ) Defendant. )

IN THE CIRCUIT COURT OF GREENE COUNTY STATE OF MISSOURI., ) Plaintiff, ) Case No. v. ) ), ) Defendant. ) TO PLAINTIFF IN THE CIRCUIT COURT OF GREENE COUNTY STATE OF MISSOURI, ) Plaintiff, ) Case No. v. ) ), ) Defendant. ) DEFENDANT S FIRST INTERROGATORIES DIRECTED TO PLAINTIFF Comes now defendant, and in

More information

NLC Pools Liability Coverage Documents Volunteer Coverage Definitions

NLC Pools Liability Coverage Documents Volunteer Coverage Definitions NLC Pools Liability Coverage Documents Volunteer Coverage Definitions Pool 1 The program may at their option provide additional coverage, as provided under this Program, for extraterritorial activities

More information

1. Personal Statement

1. Personal Statement journey injury claim form WFI Insurance Limited, ABN 24 000 036 279, AFS Licence no. 241461, Freecall 1300 651 654 IMPORTANT INFORMATION - Read before completing this form. (The issuing of this form is

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form

More information

INDEPENDENT SCHOOL DISTRICT 199 Inver Grove Heights Community Schools 2990 80 th Street East Inver Grove Heights, Minnesota 55076 HEALTH AND SAFETY

INDEPENDENT SCHOOL DISTRICT 199 Inver Grove Heights Community Schools 2990 80 th Street East Inver Grove Heights, Minnesota 55076 HEALTH AND SAFETY POLICY: 807 ADOPTED: 06/25/12 INDEPENDENT SCHOOL DISTRICT 199 Inver Grove Heights Community Schools 2990 80 th Street East Inver Grove Heights, Minnesota 55076 HEALTH AND SAFETY I. PURPOSE In order to

More information

Compulsory Third Party Personal Injury Claim Notification

Compulsory Third Party Personal Injury Claim Notification Compulsory Third Party Personal Injury Claim tification To claim damages for personal injuries in a motor vehicle accident, please complete this form in BLOCK LETTERS 2. Do you have a solicitor acting

More information

Central State University (CSU) ACCIDENT PROCEDURE

Central State University (CSU) ACCIDENT PROCEDURE Central State University (CSU) ACCIDENT PROCEDURE Note: Copies of all injury reporting packets are located in your department office and/or Human Resources Department. Complete this form when the answer

More information

810. Health and Safety Policy

810. Health and Safety Policy Adopted: May 14, 2012 Model Policy 810 Revised: June 22, 2015 Orig. 2012. 810. Health and Safety Policy I. PURPOSE The Windom School District strives to provide a safe, healthy work and educational environment

More information

Combined Insurance Claim Form

Combined Insurance Claim Form Combined Insurance Claim Form Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims Please read these important instructions on how to complete the attached Claim Form.

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM (If there is not enough room on this form for your answers, please attach a separate sheet, indicating the Section and Question you wish to complete.) Please lodge your claim to

More information

Short-Term Disability Income Benefit. Employee s Statement

Short-Term Disability Income Benefit. Employee s Statement Short-Term Disability Income Benefit Employee s Statement Employee s Statement Short Term Disability Income Benefits This guide contains the forms you need to apply for disability benefits and some important

More information