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Expense Report Related to Injury Template
Clearly document and organize all expenses related to an injury for insurance, legal, or reimbursement purposes.
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Expense Report Related to Injury Template
[Your Full Name]
[Street Address]
[City, State/Province, ZIP/Postal Code]
[Phone Number]
[Email Address]
Date of Birth: [MM/DD/YYYY]
1. Injury and Case Information
Type of Incident (check or describe):
Motor vehicle accident
Workplace injury
Slip-and-fall / premises incident
Assault or violence
Sports / recreational injury
DUI-related crash
Other: [Description]
Date of Injury: [MM/DD/YYYY]
Location of Injury (City, State/Province): [Location]
Claim / Case Information (if applicable):
Insurance Company: [Name]
Claim Number: [Number]
Attorney / Law Firm (if any): [Name]
Case Number / Court File Number (if any): [Number]
2. Reporting Period
Expense Report Period From: [MM/DD/YYYY]
To: [MM/DD/YYYY]
This report covers all known, injury-related expenses incurred during the above dates.
3. Summary of Expense Categories
(You may complete this section after filling in the detailed entries.)
Medical Treatment (doctors, hospital, ER, clinics): $[Total Amount]
Prescriptions and Medications: $[Total Amount]
Medical Equipment / Supplies (braces, crutches, etc.): $[Total Amount]
Therapy / Rehabilitation / Counseling: $[Total Amount]
Transportation / Mileage / Parking: $[Total Amount]
Home Care / Assistance / Childcare: $[Total Amount]
Lost Wages (if documented here): $[Total Amount]
Other Injury-Related Expenses: $[Total Amount]
Total Injury-Related Expenses for This Period: $[Grand Total]
4. Detailed Expense Entries
(Use as many entries as needed for each expense. Copy or continue on additional pages if necessary.)
Expense 1
Date of Expense: [MM/DD/YYYY]
Provider / Vendor Name: [Hospital, Doctor, Pharmacy, Business]
Provider Type (check one):
Hospital / Emergency Room
Doctor / Clinic / Specialist
Pharmacy
Therapist / Counselor / Rehab
Transportation (taxi, rideshare, bus, mileage)
Medical Equipment / Supplies
Home Care / Childcare
Other: [Description]
Description of Expense:
[Short description, e.g., “Emergency room visit,” “Physical therapy session,” “Prescription medication,” “Taxi to follow-up appointment,” “Knee brace.”]
Category: [Medical Treatment / Medication / Equipment / Therapy / Transportation / Home Care / Lost Wages / Other]
Amount (Currency): $[Amount]
Paid By (check one):
Self
Insurance
Employer / Program
Other: [Description]
Is Reimbursement Requested for This Item? [Yes / No / Already reimbursed]
Receipt / Invoice Attached? [Yes / No]
Notes (optional):
[Any clarifying information, such as billing date vs. service date, partial payments, or claim numbers.]
Expense 2
Date of Expense: [MM/DD/YYYY]
Provider / Vendor Name: [Name]
Provider Type: [See options above]
Description of Expense:
[Short description]
Category: [Medical Treatment / Medication / Equipment / Therapy / Transportation / Home Care / Lost Wages / Other]
Amount (Currency): $[Amount]
Paid By: [Self / Insurance / Employer / Other]
Is Reimbursement Requested for This Item? [Yes / No / Already reimbursed]
Receipt / Invoice Attached? [Yes / No]
Notes:
[Optional]
Expense 3
Date of Expense: [MM/DD/YYYY]
Provider / Vendor Name: [Name]
Provider Type: [See options above]
Description of Expense:
[Short description]
Category: [Medical Treatment / Medication / Equipment / Therapy / Transportation / Home Care / Lost Wages / Other]
Amount (Currency): $[Amount]
Paid By: [Self / Insurance / Employer / Other]
Is Reimbursement Requested for This Item? [Yes / No / Already reimbursed]
Receipt / Invoice Attached? [Yes / No]
Notes:
[Optional]
Expense 4
Date of Expense: [MM/DD/YYYY]
Provider / Vendor Name: [Name]
Provider Type: [See options above]
Description of Expense:
[Short description]
Category: [Medical Treatment / Medication / Equipment / Therapy / Transportation / Home Care / Lost Wages / Other]
Amount (Currency): $[Amount]
Paid By: [Self / Insurance / Employer / Other]
Is Reimbursement Requested for This Item? [Yes / No / Already reimbursed]
Receipt / Invoice Attached? [Yes / No]
Notes:
[Optional]
(Add additional expense blocks as needed.)
5. Transportation and Mileage Log (If Applicable)
Use this section if you claim mileage or transportation costs related to injury treatment.
Trip 1
Date: [MM/DD/YYYY]
Purpose of Trip: [e.g., “Visit to orthopedic specialist,” “Physical therapy session”]
Starting Location: [Address or City]
Destination: [Clinic / Hospital / Provider Address]
Round-Trip Distance: [Number] miles / km
Type of Transportation:
Personal vehicle (mileage)
Taxi / Rideshare
Public transportation
Other: [Description]
Amount Claimed: $[Amount]
Trip 2
Date: [MM/DD/YYYY]
Purpose of Trip: [Description]
Starting Location: [Location]
Destination: [Location]
Round-Trip Distance: [Number] miles / km
Type of Transportation: [As above]
Amount Claimed: $[Amount]
(Add more trip entries as needed.)
6. Lost Wages Summary (Optional – If Included in This Report)
Employer Name: [Employer]
Employer Address: [Address]
Supervisor / HR Contact: [Name]
Phone / Email: [Contact]
Dates Absent from Work Due to Injury:
From: [MM/DD/YYYY]
To: [MM/DD/YYYY]
Normal Work Schedule: [e.g., “Monday–Friday, 8:00 a.m.–4:30 p.m.”]
Hourly Rate / Salary: [Amount]
Total Hours Missed (if hourly): [Number]
Total Gross Wages Lost (before taxes): $[Amount]
Supporting Documentation (check all attached):
Employer letter confirming time missed and pay rate
Pay stubs
Timesheets or attendance records
Doctor’s note / work status form
7. Reimbursement and Payment Information
Total Injury-Related Expenses Claimed in This Report: $[Total]
Amount Already Reimbursed by Insurance / Other Sources: $[Amount]
Net Amount Requested (if applicable): $[Amount]
Preferred Reimbursement Method:
Check by mail
Direct deposit
Other: [Description]
Payee Name (for reimbursement checks): [Name]
8. Declaration and Signature
I, [Your Full Name], declare that the information provided in this Expense Report Related to Injury is true and accurate to the best of my knowledge. The listed expenses are directly related to the injury described above. I understand that false or misleading statements may affect my claim or legal rights.
Signature: _______________________________
Printed Name: [Your Full Name]
Date: [MM/DD/YYYY]
9. For Office / Claims Use Only (Optional)
Reviewed By: [Name]
Title / Role: [Adjuster / Claims Representative / Attorney / HR]
Date of Review: [MM/DD/YYYY]
Notes / Determination:
[Brief internal notes, if used by an organization or insurer.]
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Learn more about
Expense Report Related to Injury Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
EXPENSE REPORT RELATED TO INJURY TEMPLATE FAQ
What is an expense report related to injury?
An expense report related to injury is a detailed list of costs you have paid or incurred because of an accident or injury. It typically includes medical bills, prescription costs, transportation to appointments, medical equipment, home care, and sometimes lost wages or other out-of-pocket expenses you are seeking reimbursement for.
When should I use an injury-related expense report?
You may use an injury-related expense report when filing a claim with an insurance company, submitting documentation for workers’ compensation, supporting a DUI-related crash or motor vehicle accident case, or providing proof of expenses to your attorney, employer, or the court. A clear expense report helps show what the injury has actually cost you.
What expenses can I list on an injury expense report?
Common items include: doctor and hospital bills, emergency room charges, co-pays, prescription and over-the-counter medications, physical therapy, counseling, medical devices (braces, crutches, wheelchairs), home health or caregiving support, mileage or transportation costs to appointments, parking fees, and documented lost wages. You can also include other reasonable, injury-related out-of-pocket expenses.
How do I organize receipts and proof for an injury expense report?
For each expense, keep and attach copies of receipts, invoices, bills, and payment confirmations. It often helps to number each expense entry and write that number on the matching receipt. Keep medical bills, pharmacy receipts, transportation records, and wage documentation grouped together by category and date so insurers, attorneys, or courts can easily review the information.
Can I use this injury expense report for court, settlement negotiations, or insurance claims?
Yes. This Expense Report Related to Injury Template is designed so you can present your costs in a clear, organized format for insurance adjusters, attorneys, mediators, or courts. You should still follow any specific instructions from your lawyer, insurer, or workers’ compensation program about how to submit documentation and what supporting records are required.
Can AI Lawyer help me prepare an expense report related to an injury?
Yes. AI Lawyer can help you structure and polish your injury expense report by suggesting categories, wording, and layout. You provide the actual amounts, dates, and receipts, and AI Lawyer helps turn them into a clean, readable document you can use with insurers, employers, or legal professionals. For advice about your rights, settlement value, or legal strategy, you should consult a licensed attorney.
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