Medical report form Low value personal injury claims in road traffic accidents ( 1,000 to 10,000)

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1 Medical report form Low value personal injury claims in road traffic accidents ( 1,000 to 10,000) The first report is without notes except where requested by medical experts Section A Claimant s details Claimant s full name Date of birth / / Occupation Address Postcode 1.1 Has photo ID been confirmed? Yes No If Yes, what type of photo ID was checked If No, what other ID was provided 1.2 Age of the claimant at time of accident? 1.3 Date of examination / / 1.4 Date of report / / 1.5 Name of instructing solicitors/agency 1

2 Section B History Please give a brief description of the accident, immediate symptoms and treatment. Include a history of treatment, specifying whether the claimant was treated as an in-patient or outpatient where applicable. Detail any improvement or deterioration of symptoms including dates. In the case of injuries/symptoms fully recovered, please specify the date by which there was a full recovery. Whether the claimant has ever experienced symptoms in the injured area prior to the accident and if so give full details including type of injury and date it occured. Present position reported by claimant Please detail all ongoing symptoms reported at examination 2

3 Section C Employment position/education Please give details of the claimant s employment/education at the time of the accident. Include the dates of any absences, part-time work or light duties undertaken and the nature of any light duties. Set out the claimant s current situation at work/educational establishment including any practical difficulties, symptoms and/or restrictions. Consequential effects Please state the impact on other activies such as hobbies, recreations, housework, gardening, travelling, holidays, shopping, sex life. Give details as to the claimants general state of mind. 3

4 Section D Past medical history Please refer to any relevant history based on examination or records as appropriate. Post accident records should be considered where appropriate. On examination Please state your findings on examination including the details of any restrictions arising from the accident. 4

5 Section D - continued Diagnosis opinion and prognosis Please state your overall opinion of the claimant s position to date dealing with causation and including a prognosis if possible. Set out all reported symptoms and restrictions identified under the claimant s present position. Refer to the claimant s employment/ education position and any impact to the claimants home life. Please detail whether you consider that the claimant has/will make a recovery and to what extent and when this will be reached. Identify if the claimant has any further needs, including but not limited to : - if further treatment is necessary; - if time is needed to make a final prognosis; - if a report is needed from a medical expert of a different discipline; or - if a follow up report is needed. 5

6 Section E Seatbelts Was the claimant wearing a seatbelt? Yes No Does the claimant have an exemption from wearing a seatbelt? Yes No If Yes, please state form of exemption If No, state what extent would each of the claimant s injuries have been prevented all together; have been less severe; or have been unchanged by the claimant s failure to wear a seatbelt? Section F Future treatment and rehabilitation Please give details of any further treatment and/or rehabiliation that the claimant will require. 6

7 Section G Statement of truth Civil Procedure Rule 35.3 states that it is the duty of an expert to help the court on the matters within their expertise. This duty overrides any obligation from whom he has received instructions or by whom he is paid. Where I am not able to give my opinion without qualifcation, I have stated the qualification. I confirm that I understand my duty to the court and have complied and will continue to comply with that duty. I confirm that in so far as the facts stated in my report are within my own knowledge I have made clear which they are and I believe them to be true and that the opinions I have expressed represent my true and complete professional opinion. Signature Date / / 7

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9 Stage 2 Settlement Pack Form and Response to Settlement Pack Form Low value personal injury claims in road traffic accidents ( 1,000-10,000) Claimant s full name Contact details Company name Name of case handler Claimant s representative Defendant s representative Contact details Company name Name of case handler Direct telephone number address Direct telephone number Defendant s full name address Reference number Reference number Date of claimant 1 st offer / / Date of claimant s reply to insurer / / Business days to reply to insurer Date of final response / / Business days to final response Date of insurer 1 st offer / / Business days to make offer Date of reply to claimant / / Business days from initial insurer reply Date of final response / / Business days to final response 1

10 Total gross claimant offer Total gross defendant offer Total net defendant offer Amount in dispute Stage 2 Settlement pack and response Initial claimant offer Initial defendant response Loss Policy excess Loss of use Car hire Repair costs Fares (taxis, buses, tube, etc.) Medical expenses Clothing Care/Services Claim item being pursued Yes / No / N/A Evidence attached % Interest rate Comments Value claimed Is amount agreed? Comments Value offered Loss of earnings a) Claimant Other losses b) Employer General damages % Contributory negligence deductions Total net claimant offer % Contributory negligence deductions Offer less contributory negligence deductions CRU deductions 2

11 Claimant responses to defendant replies Defendant responses to claimant replies Date Date Date Date / / / / / / / / Final claimant offer Date made Final defendant offer Date made / / / / Comments Comments Initial amount in dispute Total amount remaining in dispute Statement of truth I believe The claimant believes that the facts stated in this claim form are true. I am duly authorised by the claimant to sign this statement. Signed Date / / (Claimant)(Claimant s solicitor) Position or office held (if sign on behalf of firm or company) 3

12 Interim Settlement Pack Form and Response to Interim Settlement Pack Form Low value personal injury claims in road traffic accidents ( 1,000-10,000) Business days to insurer response Claimant s full name Claimant s representative Defendant s representative Date of notification / / Date of insurer response / / Contact details Company name Contact details Company name Name of case handler Name of case handler Direct telephone number Direct telephone number address address Reference number Reference number 1

13 CRU deductions Agree value of documented losses to date Amount in dispute Interim settlement pack and response Claimant losses to date Defendant response Loss Policy excess Loss of use Car hire Repair costs Fares (taxis, buses, tube, etc.) Medical expenses Clothing Care/Services Claim item being pursued Yes / No / N/A Evidence attached % interest rate Comments Value claimed Is amount agreed? Comments Value offered Loss of earnings a) Claimant Other losses b) Employer General damages Total heads of damage to date % Contributory negligence deductions Total heads of damage value to date Losses agreed to date % Contributory negligence deductions Offer less contributory negligence deductions 2

14 Claimant request for interim payment Defendant responses to interim payment request Value of interim payment agreed Date Value of interim request Date / / / / Request for an interim payment accepted Detail reasons for interim payment request below Additional comments below Statement of truth I believe The claimant believes that the facts stated in this claim form are true. I am duly authorised by the claimant to sign this statement. Signed Date / / (Claimant)(Claimant s solicitor) Position or office held (if sign on behalf of firm or company) 3

15 Stage 3 Settlement Pack Form (Part A) Low value personal injury claims in road traffic accidents ( 1,000-10,000) Date of accident / / Claimant s full name Claimant s representative Defendant s representative Contact details Company name Contact details Company name Name of case handler Name of case handler Direct telephone number Direct telephone number address address Reference number Reference number 1

16 Position or office held (if sign on behalf of firm or company) Date / / Stage 3 Settlement Pack Form (Part A) Claimant Losses Claim item being pursued Evidence attached % Interest rate Claimant Defendant response Policy excess Yes / No / N/A Amount Comments Amount Comments Loss of use Car hire Repair costs Fares - taxis, buses, tube etc. Medical expenses Clothing Care/Services Loss of earnings a) Claimant Other losses b) Employer General damages CRU benefits received Statement of truth I believe The claimant believes that the facts stated in this claim form are true. I am duly authorised by the claimant to sign this statement. Up to date CRU Certificate attached Signed (Claimant) (Claimant s solicitor) 2

17 This form should be submitted to the court in a sealed envelope Stage 3 Settlement Pack Form (Part B) Low value personal injury claims in road traffic accidents ( 1,000-10,000) Date of accident / / Claimant s full name Defendant s representative Claimant s representative Contact details Company name Contact details Company name Name of case handler Name of case handler Direct telephone number address Direct telephone number address Reference number Reference number Defendant s full name Claimant final offer Defendant final offer Amount awarded 3

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