Insurance Claim Form / Insurance Injury Form Template

Insurance Claim Form / Insurance Injury Form Template

[Insurance Company Name]
[Claims Department Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Claims Phone Number]
Email: [Claims Email Address]
Claim Form Reference (if provided): [Form ID or Reference]

1. Policyholder and Claimant Information

Policyholder Full Name: [First, Middle, Last]
Policy Number: [Policy Number]
Type of Policy (check or describe):

• Auto / Motor Vehicle

• Homeowners / Renters

• General Liability

• Commercial / Business Policy

• Other: [Describe]

Claimant Full Name (if different from Policyholder): [Full Name]
Relationship to Policyholder: [Self / Spouse / Child / Employee / Other]

Date of Birth: [MM/DD/YYYY]
Phone Number: [Primary Phone]
Email Address: [Email]

Mailing Address:
[Street Address]
[City, State/Province, ZIP/Postal Code]

2. Incident Information

Type of Incident (check or describe):

• Motor vehicle accident (may include DUI-related case)

• Slip-and-fall / trip-and-fall

• Premises liability (on property or business)

• Workplace injury (if covered by this policy)

• Assault or violence

• Other: [Describe]

Incident Date: [MM/DD/YYYY]
Incident Time: [HH:MM a.m./p.m.]

Incident Location (street, business, city, state/province):
[Location description]

Was law enforcement, security, or another authority notified? [Yes / No]
If Yes, specify:

• Agency / Department: [Name]

• Officer / Contact Name (if known): [Name]

• Report or Case Number (if known): [Number]

3. Description of Incident

Provide a clear, factual description of what happened. Avoid guessing or assigning blame — focus on the events you experienced.

On [Date] at approximately [Time], I was:
[Describe what you were doing immediately before the incident, e.g., “driving northbound on [Street],” “walking in a grocery store aisle,” “working at my job station,” “visiting a business,” etc.]

Incident Description (step-by-step):
[Free-text narrative. Suggested points:]

• How the incident started (for example, another vehicle’s movement, a fall, a sudden impact).

• Any vehicles, equipment, substances, or hazards involved (wet floor, broken step, defective tool, another driver, etc.).

• How you fell, were struck, twisted, or otherwise injured.

• How you landed or came to rest.

• What you noticed immediately after (pain, dizziness, damage, etc.).

4. Injury Information

List every body part injured in this incident and your symptoms.

Body Part(s) Injured:
[Example: neck, lower back, right shoulder, left knee, head, etc.]

Type(s) of Injury (check all that apply and describe):

• Bruise / contusion – [Description]

• Cut / laceration – [Description]

• Sprain / strain – [Description]

• Suspected fracture / fracture – [Description]

• Concussion / head injury – [Description]

• Soft tissue injury – [Description]

• Burn (thermal / chemical / electrical) – [Description]

• Other: [Describe]

Current Symptoms (in your own words):
[Describe pain, stiffness, weakness, numbness, headaches, dizziness, sleep issues, emotional impact, etc.]

Pain Level Today (0–10; 0 = no pain, 10 = worst pain imaginable):
Pain Score: [0–10]

5. Medical Treatment

Did you receive medical treatment immediately after the incident? [Yes / No]

If Yes, check and complete:

• First aid at the scene – Provided by: [Name/Role]

• Ambulance / EMS – Transported to: [Hospital/Facility Name]

• Emergency room visit – Facility: [Name] – Date: [MM/DD/YYYY]

• Urgent care / clinic visit – Facility: [Name] – Date: [MM/DD/YYYY]

List all medical providers you have seen for this injury (doctors, hospitals, physical therapists, chiropractors, counselors, etc.):

Provider 1:
Name: [Name]
Specialty: [Specialty, e.g., Emergency Medicine, Orthopedics, Family Medicine]
Facility: [Name]
City/State: [City/State]
First Visit Date: [MM/DD/YYYY]
Most Recent Visit Date: [MM/DD/YYYY]

Provider 2:
Name: [Name]
Specialty: [Specialty]
Facility: [Name]
City/State: [City/State]
First Visit Date: [Date]
Most Recent Visit Date: [Date]

[Add additional providers as needed.]

Treatment Received (check all that apply):

• Physical examination and advice

• X-rays

• CT scan / MRI / other imaging

• Prescription medications

• Over-the-counter medications

• Physical therapy

• Chiropractic treatment

• Injections (e.g., steroid, pain relief)

• Surgery or procedure

• Counseling / psychological support

• Other: [Describe]

Have any providers given you written work or activity restrictions?

• Yes – describe: [e.g., “No lifting over 10 lbs,” “No driving,” “No sports activities.”]

• No

• Not sure

6. Time Off Work / School and Functional Impact

Have you missed work or school because of this injury?

• Yes

• No

If Yes, specify:

Employer / School Name: [Name]
Job Title or Student Status: [Job / “Student” / Other]

Dates Absent From Work / School:
From: [MM/DD/YYYY]
To: [MM/DD/YYYY or “Ongoing”]

Approximate Number of Full Days Missed: [Number]
Approximate Number of Partial Days (left early/arrived late): [Number]

Describe how the injury affects your ability to work, attend school, or perform daily tasks (in your own words):
[Example: difficulty standing, sitting, lifting, concentrating, sleeping, driving, performing housework, caring for family, etc.]

7. Property Damage (If Applicable)

Was any property damaged in the incident (such as a vehicle, personal items, or business property)?

• Yes

• No

If Yes, list each item:

Property Item 1:
Type of Property: [e.g., vehicle, phone, glasses, clothing, equipment]
Description (make, model, year, serial, etc.): [Description]
Extent of Damage: [Minor / Moderate / Severe – brief explanation]

Property Item 2:
Type of Property: [Description]
Extent of Damage: [Description]

[Add additional items as needed.]

Repair estimates or invoices available? [Yes / No]

8. Expenses and Financial Impact

You may attach a separate expense log, but note key items here.

Types of Expenses Incurred (check all that apply):

• Medical bills (hospital, doctors, clinics)

• Prescription medications

• Over-the-counter medications

• Physical therapy / rehabilitation

• Medical devices or equipment (braces, crutches, etc.)

• Transportation / mileage / taxis / rideshare to appointments

• Parking fees at medical facilities

• Home care, assistance, or childcare

• Lost wages or income

• Other injury-related expenses: [Describe]

Approximate Total Injury-Related Expenses To Date: $[Amount]
(You may provide detailed bills and receipts separately.)

9. Other Insurance Coverage

Do you have other insurance that might apply to this incident?

Health Insurance:

• Health Insurance Company: [Name]

• Policy / Member Number: [Number]

Auto Insurance (if not this insurer):

• Auto Insurance Company: [Name]

• Policy Number: [Number]

Other Insurance (check and describe, if any):

• Workers’ compensation

• Other liability policy

• Disability insurance

• Other: [Describe]

10. Witnesses and Supporting Documents

Were there any witnesses to the incident?

• Yes

• No

• Not sure

Witness 1:
Name: [Name]
Phone / Email: [Contact]
Short Description of What They Saw (if known): [Summary]

Witness 2:
Name: [Name]
Phone / Email: [Contact]

Supporting Documents You Have (check all that apply):

• Police or incident reports

• Medical records or summaries

• Medical bills and receipts

• Wage or employment verification

• Photos of injuries

• Photos of scene or property damage

• Other: [Describe]

11. Prior Injuries or Conditions (If Relevant)

Before this incident, had you ever injured the same body part(s)?

• Yes

• No

If Yes, describe briefly (including approximate dates and whether you had recovered before this new incident):
[Example: “Prior lower back strain in 2019; symptoms had resolved before this accident.”]

12. Additional Information

Use this section for any other information that may help the insurance company understand your claim.

Additional Information:
[Free-text narrative]

13. Declaration and Signature

Please read carefully before signing.

I, [Claimant Full Name], declare that the information provided in this Insurance Claim Form / Insurance Injury Form is true, correct, and complete to the best of my knowledge and belief. I understand that this information may be used by the insurance company to evaluate my claim and that false or misleading statements may affect coverage, benefits, or legal rights.

I understand that I may wish to consult with an attorney or other professional before submitting this form.

Claimant Signature: _______________________________
Printed Name: [Claimant Full Name]
Date Signed: [MM/DD/YYYY]

Place Signed (City, State/Province): [Location]

[Optional – For Insurance Company Use Only]

Claim Received By (Name and Title): [Name, Title]
Date Received: [MM/DD/YYYY]
Claim Number: [Assigned Claim Number]

Internal Notes:
[Short internal notes, if used by the insurer.]