Personal Injury Claim Form Template: Damages, Evidence & Filing

Personal Injury Claim Form Template

[Insurance Company / Business / Property Owner / Other Recipient Name]

[Claims or Risk Management Department, if applicable]

[Street Address]

[City, State/Province, ZIP/Postal Code]

Phone: [Phone Number]

Email: [Email Address]

1. Claimant Information

Full Legal Name: [First, Middle, Last]

Date of Birth: [MM/DD/YYYY]

Age: [Age]

Gender: [Gender]

Home Address:

[Street Address]

[City, State/Province, ZIP/Postal Code]

Primary Phone: [Phone Number]

Secondary Phone (optional): [Phone Number]

Email Address: [Email Address]

Preferred Contact Method: [Phone / Email / Mail / Other]

2. Policy, Claim, or Reference Information

If this claim involves insurance, complete as much as you can.

Your Insurance Company (if any): [Name]

Policy Number: [Policy Number]

Other Party’s Insurance (if known): [Company Name]

Policy or Claim Number (if known): [Number]

Internal Reference or File Number (if provided by recipient): [Number]

3. Type of Incident

Type of Incident (check or describe):

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

• Slip-and-fall / trip-and-fall

• Premises incident (hazardous condition on property)

• Workplace injury (if handled as a personal injury claim)

• Dog bite / animal incident

• Assault or intentional harm

• Sports or recreational injury

• Other: [Describe]

Motor vehicle accident (may include DUI-related crash)

Slip-and-fall / trip-and-fall

Premises incident (hazardous condition on property)

Workplace injury (if handled as a personal injury claim)

Dog bite / animal incident

Assault or intentional harm

Sports or recreational injury

Other: [Describe]

4. Date, Time, and Location of Incident

Incident Date: [MM/DD/YYYY]

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

Location of Incident (street address, business name, or landmark):

[Location description]

City: [City]

State/Province: [State/Province]

Country: [Country]

Setting (check one):

• Public place or business

• Private residence

• Workplace or job site

• Roadway / parking lot

• School / sports facility

• Other: [Describe]

Public place or business

Private residence

Workplace or job site

Roadway / parking lot

School / sports facility

5. Description of Incident

Provide a clear, factual description of how the incident occurred. Avoid opinions or legal conclusions; focus on what happened.

On [Date] at approximately [Time], I was:

[Describe what you were doing immediately before the incident, e.g., “walking through the store aisle,” “driving northbound on [Street],” “working on a ladder,” “visiting the property,” etc.]

Incident Description (step-by-step narrative):

[Free-text description. Suggested points:]

• What you saw or noticed before the incident (e.g., wet floor, uneven surface, speeding vehicle, loose object).

• How the incident occurred (slip, trip, fall, collision, impact, sudden movement, etc.).

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

• Where you landed and what body parts were affected.

• Any comments or actions by other people immediately afterward.

What you saw or noticed before the incident (e.g., wet floor, uneven surface, speeding vehicle, loose object).

How the incident occurred (slip, trip, fall, collision, impact, sudden movement, etc.).

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

Where you landed and what body parts were affected.

Any comments or actions by other people immediately afterward.

6. Conditions or Hazards Involved

Describe any conditions or hazards that contributed to the incident (if known):

Surface / Environment:

• Wet or slippery floor

• Uneven surface / hole / crack

• Loose objects or debris

• Poor lighting

• Broken or missing handrail

• Obstructed walkway

• Weather-related condition (rain, ice, snow)

• Other: [Describe]

Wet or slippery floor

Uneven surface / hole / crack

Loose objects or debris

Poor lighting

Broken or missing handrail

Obstructed walkway

Weather-related condition (rain, ice, snow)

Equipment / Vehicle / Object Involved (if any):

[Example: “Shopping cart,” “company equipment,” “other vehicle,” “defective step,” etc.]

If the incident was a motor vehicle accident, briefly describe the vehicles and directions of travel:

[Free-text]

7. Injury Information

List every part of your body that was injured in this incident.

Body Part(s) Injured:

[Example: “Neck,” “lower back,” “right shoulder,” “left knee,” “head,” “right wrist,” etc.]

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

• Bruise / contusion – [Description]

• Cut / laceration – [Description]

• Abrasion / scrape – [Description]

• Sprain / strain / whiplash – [Description]

• Suspected fracture / fracture – [Description]

• Concussion / head injury – [Description]

• Soft tissue injury (muscles, ligaments, tendons) – [Description]

• Internal injury (suspected or diagnosed) – [Description]

• Other: [Describe]

Bruise / contusion – [Description]

Cut / laceration – [Description]

Abrasion / scrape – [Description]

Sprain / strain / whiplash – [Description]

Suspected fracture / fracture – [Description]

Concussion / head injury – [Description]

Soft tissue injury (muscles, ligaments, tendons) – [Description]

Internal injury (suspected or diagnosed) – [Description]

Symptoms noticed immediately after the incident:

[Example: pain, swelling, dizziness, headache, nausea, numbness, weakness.]

Current symptoms (in your own words):

[Free-text description of pain, limitations, headaches, sleep issues, emotional effects, etc.]

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

Pain Score: [0–10]

8. Medical Treatment

Initial medical care received (check all that apply):

• No treatment immediately after incident

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

• Ambulance / EMS assessment

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

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

• Primary care doctor – Provider: [Name] – Date: [MM/DD/YYYY]

• Other: [Describe]

No treatment immediately after incident

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

Ambulance / EMS assessment

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

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

Primary care doctor – Provider: [Name] – Date: [MM/DD/YYYY]

Ongoing or follow-up treatment (list all providers you have seen):

Provider 1:

Name: [Name]

Specialty: [e.g., Orthopedics, Physical Therapy, Chiropractic, Neurology]

Facility: [Name]

City/State: [City, State/Province]

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/Province]

First Visit Date: [Date]

Most Recent Visit Date: [Date]

[Add additional providers as needed.]

Types of treatment received (check all that apply):

• Physical examination and advice

• X-rays

• MRI / CT scan / other imaging

• Laboratory tests

• Prescription medications

• Over-the-counter medications

• Physical therapy / rehabilitation

• Chiropractic care

• Injections (pain management, steroid, etc.)

• Surgery or procedure

• Counseling or psychological support

• Other: [Describe]

Physical examination and advice

X-rays

MRI / CT scan / other imaging

Laboratory tests

Prescription medications

Over-the-counter medications

Physical therapy / rehabilitation

Chiropractic care

Injections (pain management, steroid, etc.)

Surgery or procedure

Counseling or psychological support

Have you been given written work or activity restrictions?

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

• No

• Not sure

Yes – describe: [e.g., “No lifting over 10 lbs,” “Limited standing,” “No driving.”]

No

Not sure

9. Work, School, and Daily-Life Impact

Employment status at time of incident:

• Employed full-time

• Employed part-time

• Self-employed

• Independent contractor

• Unemployed

• Student

• Other: [Describe]

Employed full-time

Employed part-time

Self-employed

Independent contractor

Unemployed

Student

Employer / School Name: [Name]

Job Title or Student Status: [Title / “Student”]

Have you missed work or school because of this injury?

• Yes

• No

Yes

If Yes, fill in:

Dates absent: From [MM/DD/YYYY] to [MM/DD/YYYY or “Ongoing”]

Approximate full days missed: [Number]

Approximate partial days (left early / arrived late): [Number]

Briefly describe how your injury affects your work, school, or daily activities (for example, difficulty standing, lifting, concentrating, driving, caring for family):

[Free-text narrative]

10. Property Damage (If Applicable)

Was any property damaged in the incident (vehicle, clothing, glasses, phone, equipment, etc.)?

If Yes, list each item:

Item 1:

Type of Property: [e.g., vehicle, eyeglasses, phone]

Description (make/model if applicable): [Description]

Approximate Repair or Replacement Cost: $[Amount]

Item 2:

Type of Property: [Description]

Approximate Cost: $[Amount]

[Add additional items as needed.]

11. Expenses and Financial Losses

You may attach a separate expense or loss log; list the main categories here.

Types of losses or expenses you are claiming (check all that apply):

• Medical bills (hospital, doctors, therapy, tests)

• Prescription medications

• Over-the-counter medications or supplies

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

• Transportation to medical appointments (mileage, taxis, rideshare, parking)

• Home care, assistance, or childcare

• Lost wages or income

• Property damage

• Other out-of-pocket expenses: [Describe]

Medical bills (hospital, doctors, therapy, tests)

Over-the-counter medications or supplies

Medical devices / equipment (braces, crutches, etc.)

Transportation to medical appointments (mileage, taxis, rideshare, parking)

Home care, assistance, or childcare

Lost wages or income

Property damage

Other out-of-pocket expenses: [Describe]

Approximate total amount of all claimed expenses and financial losses (if known): $[Amount]

Describe any documents you can provide (bills, receipts, pay stubs, repair estimates, etc.):

[Free-text]

12. Witnesses and Reports

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]

Did law enforcement, security, or another authority prepare a report?

• Yes – Agency: [Police / Security / Other]

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

• No

• Not sure

Yes – Agency: [Police / Security / Other]

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

13. Prior Injuries or Conditions (If Relevant)

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

If Yes, briefly describe:

• Prior injury or condition: [Description]

• Approximate date(s): [Dates]

• Whether you had recovered or were stable before this incident: [Explanation]

Prior injury or condition: [Description]

Approximate date(s): [Dates]

Whether you had recovered or were stable before this incident: [Explanation]

14. Attachments Checklist

Check all documents you are attaching or can provide on request:

• Photographs of scene or hazard

• Photographs of injuries

• Medical records or visit summaries

• Medical bills and Explanation of Benefits (EOBs)

• Wage or income records (pay stubs, tax returns, employer letter)

• Repair estimates or property damage invoices

• Police or incident reports

• Witness statements

• Other: [Describe]

Photographs of scene or hazard

Photographs of injuries

Medical records or visit summaries

Medical bills and Explanation of Benefits (EOBs)

Wage or income records (pay stubs, tax returns, employer letter)

Repair estimates or property damage invoices

Police or incident reports

Witness statements

15. Declaration and Signature

Please read carefully before signing.

I, [Claimant Full Name], declare that the information provided in this Personal Injury Claim Form is true, correct, and complete to the best of my knowledge and belief. I understand that this information may be used by the recipient, insurers, or other parties to evaluate my claim.

I understand that this form does not by itself determine legal fault, coverage, or the value of my claim, and that I may wish to consult a licensed attorney before signing or submitting it.

Signature: _______________________________

Printed Name: [Claimant Full Name]

Date Signed: [MM/DD/YYYY]

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