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]

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]

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.

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]

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]

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]

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]

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

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]

Employer / School Name: [Name]

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

Have you missed work or school because of this injury?

• Yes

• No

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]

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

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]

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]

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]