Insurance Claim Form Template: Injury Report & Coverage

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]

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]

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

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]

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.).

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]

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]

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]

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]

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

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

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

Yes

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)?

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]

Medical bills (hospital, doctors, clinics)

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]

Health Insurance Company: [Name]

Policy / Member Number: [Number]

Auto Insurance (if not this insurer):

• Auto Insurance Company: [Name]

• Policy Number: [Number]

Auto Insurance Company: [Name]

Policy Number: [Number]

Other Insurance (check and describe, if any):

• Workers’ compensation

• Other liability policy

• Disability insurance

• Other: [Describe]

Workers’ compensation

Other liability policy

Disability insurance

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]

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

11. Prior Injuries or Conditions (If Relevant)

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

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.]