Chapter 3 Personal Injury Protection (PIP) Benefits and Uninsured/Underinsured Motorist TX_PI_Forms_Fullbook.indb 125 10/24/14 12:29:54 PM
FORM 3-001 LETTER REQUESTING PIP APPLICATION [NAME OF INSURANCE COMPANY] [ADDRESS OF INSURANCE COMPANY] Attention: PIP Claims Department RE: Your Insured: [CLIENT] Claimant: [CLAIMANT] Policy No.: [POLICY NUMBER] Claim No.: [CLAIM NUMBER] D/A: [D/A] Dear Sir/Madam: Please be advised that this office has been retained by [CLIENT] to represent his/her interest in a claim for personal injuries sustained as a result of a motor vehicle accident that occurred on or about [D/A]. It is my intention to seek compensation under insured s Personal Injury Protection (PIP) coverage for all losses and damages to [CLIENT] sustained as a result of this accident. Please forward to our office the appropriate application for Personal Injury Protection benefits for completion by my client. I am enclosing a self-addressed stamped envelope for your reply. If you have any questions, please feel free to contact me. 126 Lanier s Texas Personal Injury Forms - 3rd Edition PERSONAL INJURY PROTECTION (PIP) BENEFITS TX_PI_Forms_Fullbook.indb 126 10/24/14 12:29:54 PM
FORM 3-002 LETTER TO CLIENT FORWARDING PIP APPLICATION [CLIENT] [ADDRESS] RE: Date of Accident: [D/A] Dear [MR./MS.] [CLIENT S LAST NAME]: In connection with the above date of accident, enclosed please find an Application for Personal Injury Protection Benefits (PIP) for your signature. Please sign only where indicated and return to me in the self-addressed stamped envelope provided for your convenience. In addition, I would appreciate your providing on a separate piece of paper any information which has not been filled in on this form. If you have any questions regarding this matter, please feel free to call upon me. PERSONAL INJURY PROTECTION (PIP) BENEFITS Lanier s Texas Personal Injury Forms - 3rd Edition 127 TX_PI_Forms_Fullbook.indb 127
FORM 3-003 LETTER FORWARDING PIP APPLICATION TO INSURANCE CARRIER [PIP CARRIER] [PIP CARRIER ADDRESS] Attention: [ADJUSTER S NAME] RE: My Client: [CLIENT] Your Insured: [INSURED] Policy No.: [POLICY NUMBER] Claim No.: [CLAIM NUMBER] D/A: [D/A] Dear [MR./MS.] [ADJUSTER S LAST NAME]: Enclosed please find the completed and properly executed Application for Personal Injury Protection Benefits (PIP) in regards to the above matter. Please note that upon receipt, I will forward medical bills directly to your attention. If you have any questions regarding this matter, please feel free to call upon me. 128 Lanier s Texas Personal Injury Forms - 3rd Edition PERSONAL INJURY PROTECTION (PIP) BENEFITS TX_PI_Forms_Fullbook.indb 128
FORM 3-004 LETTER SUBMITTING MEDICAL BILLS TO PIP CARRIER FOR PAYMENT [INSURANCE CARRIER] [INSURANCE CARRIER ADDRESS] Attention: [PIP ADJUSTER] RE: My Client: [CLIENT] Your Insured: [INSURED] Claim No.: [CLAIM NUMBER] Policy No.: [POLICY NUMBER] D/A: [D/A] Dear [MR./MS.] [ADJUSTER S LAST NAME]: In regard to the above matter, please find enclosed the following bill: 1. Bill from [PROVIDER NAME] for services rendered on [DATE OF SERVICE] in the amount of $[AMOUNT OF BILL]. Upon review of the enclosed medical bills, please forward Personal Injury Protection (PIP) payment directly to my office. Thank you for your anticipated cooperation in this matter. PERSONAL INJURY PROTECTION (PIP) BENEFITS Lanier s Texas Personal Injury Forms - 3rd Edition 129 TX_PI_Forms_Fullbook.indb 129
FORM 3-005 LETTER REQUESTING PIP PAYMENT LEDGER [PIP CARRIER] [PIP CARRIER ADDRESS] Attention: [ADJUSTER NAME] RE: Your Insured: [CLIENT] Claimant: [CLAIMANT] Policy No.: [POLICY NUMBER] Claim No.: [CLAIM NUMBER] D/A: [D/A] Dear [MR./MS.] [ADJUSTER S LAST NAME]: At this time we are hereby requesting that you provide our office with a copy of the PIP payment record for the above referenced claim. I have enclosed a self-addressed stamped envelope for your convenience. Thank you for your anticipated cooperation in this matter. Please feel free to contact our office if you should have any questions. 130 Lanier s Texas Personal Injury Forms - 3rd Edition PERSONAL INJURY PROTECTION (PIP) BENEFITS TX_PI_Forms_Fullbook.indb 130
FORM 3-006 INITIAL NOTICE TO UNINSURED (UM)/UNDERINSURED (UIM) MOTORIST CARRIER [NAME OF UM/UIM CARRIER] [ADDRESS OF CARRIER] Attention: Uninsured/Underinsured Motorist Claim Department RE: My Client: [CLIENT] Your Insured: [DEFENDANT] Policy No: [POLICY NUMBER] Claim No: [CLAIM NUMBER] D/A: [DATE OF ACCIDENT] Dear Sir/Madam: Your file may reflect that this office represents [CLIENT] for personal injuries sustained as a result of a motor vehicle accident occurring on [D/A]. Please accept this letter as notice of a potential uninsured and/or underinsured motorist claim under your insured s policy. If you have any questions regarding this matter, or should you require additional information at this time, please feel free to call upon me. PERSONAL INJURY PROTECTION (PIP) BENEFITS Lanier s Texas Personal Injury Forms - 3rd Edition 131 TX_PI_Forms_Fullbook.indb 131
FORM 3-007 NOTICE LETTER TO UNDERINSURED (UIM) MOTORIST CARRIER AND REQUEST FOR PERMISSION TO SETTLE [ADJUSTER NAME] [INSURANCE COMPANY] [INSURANCE ADDRESS] RE: Insured: [NAME OF INSURED] Your claim number: [INSURANCE CLAIM NUMBER] Policy number: [INSURANCE POLICY NUMBER] Date of Accident: [D/A] Dear [ADJUSTER NAME]: Please be advised that I represent [NAME OF CLIENT] for any and all claims [HE/SHE] may have as a result of injuries [HE/SHE] sustained in a motor vehicle collision which occurred on [D/A] and was due to the negligence of [DEFENDANT DRIVER]. Please direct all correspondence in this matter to me. [DEFENDANT DRIVER] was underinsured for the damages HE/SHE] has caused and which resulted from [HIS/HER] negligence resulting in the collision with [CLIENT NAME]. As such I will be making an underinsured claim. Attached please find confirmation that [DEFENDANT DRIVER] only has $[AMOUNT OF INSURANCE LIMITS] in liability insurance. Also attached please find medical bills for [CLIENT NAME] that total well over the insurance amount. I am having an asset check done for [DEFEN- DANT DRIVER] but I do not believe that [HE/SHE] has assets sufficient to attempt to recover against. I will forward you the results of that check when it is completed. Finally, I am requesting your written permission to compromise the underlying liability claim. Please forward such to me as soon as reasonably possible. 132 Lanier s Texas Personal Injury Forms - 3rd Edition PERSONAL INJURY PROTECTION (PIP) BENEFITS TX_PI_Forms_Fullbook.indb 132
Form 3-007 Notice Letter to Underinsured (UIM) Motorist Carrier and Request for Permission to Settle If you have any questions or comments please feel free to call me. PERSONAL INJURY PROTECTION (PIP) BENEFITS Lanier s Texas Personal Injury Forms - 3rd Edition 133 TX_PI_Forms_Fullbook.indb 133
FORM 3-008 LETTER TO UNDERINSURED (UIM) MOTORIST CARRIER REQUESTING INSURANCE POLICY [ADJUSTER NAME] [INSURANCE COMPANY] [INSURANCE ADDRESS] RE: Insured: [NAME OF INSURED] Your claim number: [INSURANCE CLAIM NUMBER] Policy number: [INSURANCE POLICY NUMBER] Date of Accident: [D/A] Dear [ADJUSTER NAME]: I would respectfully request a copy of [CLIENT] s insurance policy (Policy No. [NUMBER]) that covers [HIS/HER] [YEAR AND MAKE OF VEHICLE] which was involved in the automobile accident that occurred on [D/A]. If you have any questions or comments please feel free to call me. Thank you for your attention to this matter. 134 Lanier s Texas Personal Injury Forms - 3rd Edition PERSONAL INJURY PROTECTION (PIP) BENEFITS TX_PI_Forms_Fullbook.indb 134
FORM 3-009 DEMAND LETTER TO UNDERINSURED (UIM) MOTORIST CARRIER [ADJUSTER NAME] [INSURANCE COMPANY] [INSURANCE ADDRESS] RE: Insured: [NAME OF INSURED] Your claim number: [INSURANCE CLAIM NUMBER] Policy number: [INSURANCE POLICY NUMBER] Date of Accident: [D/A] Dear [ADJUSTER NAME]: As you are aware, you previously provided us permission to settle the underlying claim via letter dated. We have resolved that claim for $[POLICY LIMIT AMOUNT], which was the limit of liability insurance. I understand the limits for the underinsured policy covering the vehicle [CLIENT] was driving are $[POLICY LIMIT AMOUNT]. We hereby demand $[POLICY LIMIT AMOUNT] to settle [CLIENT] s underinsured claim. We have previously sent you documentation of medical records and bills which show the severe extent of [CLIENT] s injuries. Attached is the accident report which shows the clear liability in this case. Given the liability and damages and your first party obligations in this matter, this is easily a limits case and we expect prompt payment. If you have any questions or comments please feel free to call me. PERSONAL INJURY PROTECTION (PIP) BENEFITS Lanier s Texas Personal Injury Forms - 3rd Edition 135 TX_PI_Forms_Fullbook.indb 135