Personal Injury Insurance Claim
Personal Injury Insurance Claim
Claimant Information
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Full Name: |
[Your Name] |
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Email Address: |
[Your Email] |
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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
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Fractured right wrist.
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Sprained right ankle.
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Multiple bruises and abrasions on the right leg.
Medical Treatment
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Initial Treatment: |
Emergency Room at Springfield General Hospital |
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Attending Physician: |
Dr. Jane Smith |
Treatment Received:
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X-rays of the wrist and ankle.
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Casting of the right wrist.
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Prescription for pain medication.
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Follow-up visits are recommended for physical therapy.
Supporting Documents
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Medical report from Springfield General Hospital.
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Photographs of the injury and the area where the incident occurred.
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Witness statements from bystanders who saw the incident.
Claim Amount
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Medical Expenses: |
$2,500 |
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Prescribed Medications: |
$200 |
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Physical Therapy: |
$1,000 |
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Lost Wages: |
$1,500 |
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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]
