Personal Injury Insurance Claim
Claimant Information
Full Name: | [Your Name] |
Email Address: | [Your Email] |
Policy Number: | XYZ123456789 |
Incident Details
Date of Incident: October 2, 2056
Time of Incident: 3:45 PM
Location of Incident: Central Park, Springfield, IL
Description of Incident:
On October 2, 2056, at approximately 3:45 PM, I was walking through Central Park when I tripped over an uneven sidewalk. As a result, I fell and sustained injuries to my right leg and wrist.
Injuries Sustained
Medical Treatment
Initial Treatment: | Emergency Room at Springfield General Hospital |
Attending Physician: | Dr. Jane Smith |
Treatment Received:
X-rays of the wrist and ankle.
Casting of the right wrist.
Prescription for pain medication.
Follow-up visits are recommended for physical therapy.
Supporting Documents
Medical report from Springfield General Hospital.
Photographs of the injury and the area where the incident occurred.
Witness statements from bystanders who saw the incident.
Claim Amount
Medical Expenses: | $2,500 |
Prescribed Medications: | $200 |
Physical Therapy: | $1,000 |
Lost Wages: | $1,500 |
Other Costs (transportation, etc.): | $300 |
Total Claim Amount: $5,500
Conclusion
I respectfully request reimbursement for the total claim amount of $5,500, as detailed above. The supporting documentation has been included to substantiate the claim. I appreciate your prompt attention to this matter and look forward to your response.
Claimant's Name: [Your Name]
Date: [DATE SIGNED]
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