Personal Injury Demand Letter Template: Settlement & Damages

Personal Injury Demand Letter Template

[Your Full Name]

[Street Address]

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

[Phone Number]

[Email Address]

[Date]

[Claims Adjuster Full Name]

[Insurance Company Name]

[Claims Department / Address Line 1]

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

Re: Personal Injury Claim – [Your Name]

Claim Number: [Claim Number]

Date of Loss: [MM/DD/YYYY]

Insured: [Name of Insured / At-Fault Party]

1. Introduction and Purpose of This Letter

Dear [Mr./Ms./Mx.] [Adjuster Last Name]:

This letter is my formal settlement demand arising from the personal injuries and damages I sustained in the incident that occurred on [Date of Incident] in [City, State/Province]. Based on the facts of the accident, my medical treatment, documented expenses, loss of income, and ongoing pain and suffering, I respectfully submit this demand for full and fair compensation.

2. Liability and Description of the Incident

On [Date of Incident] at approximately [Time] in [Location – street/intersection/business premises], I was [briefly describe what you were doing – e.g., “lawfully driving northbound on [Street],” “walking through the store aisle,” “working at my job site,” etc.].

The incident occurred as follows:

• [Describe the actions of the at-fault party. For example: “Your insured failed to yield the right of way and struck my vehicle in the intersection,” or “The store failed to clean or warn about liquid on the floor.”]

• [Explain how the impact or fall happened and how your body was affected.]

• [Describe any immediate symptoms you felt at the scene.]

[Describe the actions of the at-fault party. For example: “Your insured failed to yield the right of way and struck my vehicle in the intersection,” or “The store failed to clean or warn about liquid on the floor.”]

[Explain how the impact or fall happened and how your body was affected.]

[Describe any immediate symptoms you felt at the scene.]

As a result of these actions and conditions, your insured/your insured’s premises caused the incident and my resulting injuries. To my knowledge, I did not engage in any negligent conduct that contributed to this event.

3. Injuries Sustained

Immediately after the incident, I experienced [briefly list initial symptoms – e.g., neck pain, back pain, headache, shoulder pain, knee pain, etc.].

The primary injuries diagnosed include:

• [Injury 1 – e.g., “Cervical strain/whiplash”]

• [Injury 2 – e.g., “Lumbar strain”]

• [Injury 3 – e.g., “Right knee contusion and sprain”]

• [Any fractures, tears, concussions, or other significant conditions]

[Injury 1 – e.g., “Cervical strain/whiplash”]

[Injury 2 – e.g., “Lumbar strain”]

[Injury 3 – e.g., “Right knee contusion and sprain”]

[Any fractures, tears, concussions, or other significant conditions]

These injuries have caused ongoing pain, limited movement, and disruption of my normal work, household activities, and daily life, as described below.

4. Medical Treatment Summary

Following the incident, I obtained medical care as summarized below:

• [Date] – [Emergency Room / Urgent Care / Initial Clinic] at [Facility Name]. Evaluated for [symptoms]. [X-rays/CT/MRI/other tests] performed. Diagnosed with [diagnoses]. Prescribed [medications] and initial restrictions.

• [Date range] – Follow-up visits with [Primary Care Provider / Specialist Name] for continuing symptoms in [body parts]. Recommended [rest, medications, physical therapy, referrals, etc.].

• [Date range] – Physical therapy at [Clinic Name]. [Number] sessions focusing on [body parts, range-of-motion work, strengthening, manual therapy, etc.].

• [Any injections, procedures, surgery, chiropractic care, counseling, or additional treatment.]

[Date] – [Emergency Room / Urgent Care / Initial Clinic] at [Facility Name]. Evaluated for [symptoms]. [X-rays/CT/MRI/other tests] performed. Diagnosed with [diagnoses]. Prescribed [medications] and initial restrictions.

[Date range] – Follow-up visits with [Primary Care Provider / Specialist Name] for continuing symptoms in [body parts]. Recommended [rest, medications, physical therapy, referrals, etc.].

[Date range] – Physical therapy at [Clinic Name]. [Number] sessions focusing on [body parts, range-of-motion work, strengthening, manual therapy, etc.].

[Any injections, procedures, surgery, chiropractic care, counseling, or additional treatment.]

As of the date of this letter, my treatment status is: [e.g., “ongoing,” “released from active treatment but with residual symptoms,” “awaiting further evaluation,” etc.]. Copies of my medical records and bills are enclosed or will be provided upon request.

5. Medical Expenses (Special Damages – Medical)

To date, my known medical expenses related to this incident are as follows (billed amounts before any insurance adjustments):

• [Provider / Facility Name] – $[Amount]

• [Provider / Facility Name] – $[Amount]

• [Physical Therapy / Rehabilitation] – $[Amount]

• [Imaging / Diagnostic Tests] – $[Amount]

• [Pharmacy / Medications] – $[Amount]

• [Other Medical Expenses] – $[Amount]

[Provider / Facility Name] – $[Amount]

[Physical Therapy / Rehabilitation] – $[Amount]

[Imaging / Diagnostic Tests] – $[Amount]

[Pharmacy / Medications] – $[Amount]

[Other Medical Expenses] – $[Amount]

Total Medical Expenses to Date: $[Total Medical Bills]

All available medical bills and statements supporting these amounts are enclosed or can be provided upon request.

6. Lost Income and Loss of Earning Capacity

Due to my injuries and related limitations, I have suffered a loss of income. In particular:

• I was unable to work from [Start Date of Absence] to [End Date or “Ongoing”].

• During this period, I missed approximately [Number] full workdays and [Number] partial workdays.

• Before the incident, my average earnings were approximately $[Amount] per [hour/week/month].

I was unable to work from [Start Date of Absence] to [End Date or “Ongoing”].

During this period, I missed approximately [Number] full workdays and [Number] partial workdays.

Before the incident, my average earnings were approximately $[Amount] per [hour/week/month].

Based on this information, my current documented loss of income is:

Total Lost Income to Date: $[Total Lost Wages]

[Optional paragraph:] My symptoms and restrictions may also affect my future earning capacity. I reserve the right to supplement this portion of my claim if additional information or documentation becomes available. Employer letters, pay stubs, and/or tax records supporting my wage loss are enclosed or available upon request.

7. Pain, Suffering, and Impact on Daily Life

Beyond medical bills and lost wages, this incident has significantly affected my quality of life. Since the date of the incident:

• I experience ongoing pain in [body parts], often described as [sharp/aching/throbbing/burning]. On a 0–10 scale, my average daily pain is about [X], and at its worst can reach [Y].

• Routine activities such as [sleeping, sitting, standing, walking, driving, housework, caring for family, etc.] are now difficult and often painful.

• I have had to reduce or stop activities I previously enjoyed, including [sports, exercise, hobbies, social events, travel, etc.].

• The injuries and limitations have caused emotional distress, including [anxiety, frustration, sadness, worry about my future health and finances, etc.].

I experience ongoing pain in [body parts], often described as [sharp/aching/throbbing/burning]. On a 0–10 scale, my average daily pain is about [X], and at its worst can reach [Y].

Routine activities such as [sleeping, sitting, standing, walking, driving, housework, caring for family, etc.] are now difficult and often painful.

I have had to reduce or stop activities I previously enjoyed, including [sports, exercise, hobbies, social events, travel, etc.].

The injuries and limitations have caused emotional distress, including [anxiety, frustration, sadness, worry about my future health and finances, etc.].

These physical and emotional consequences are directly related to the incident and are supported by my treatment records and personal statements.

8. Other Out-of-Pocket Expenses

In addition to medical bills and lost income, I have incurred other reasonable and necessary expenses, including:

• Transportation to and from medical appointments (mileage, rideshare, parking): $[Amount]

• Medical devices or equipment (braces, splints, supports, etc.): $[Amount]

• Over-the-counter medications and supplies: $[Amount]

• Other documented costs (childcare, home help, etc.): $[Amount]

Transportation to and from medical appointments (mileage, rideshare, parking): $[Amount]

Medical devices or equipment (braces, splints, supports, etc.): $[Amount]

Over-the-counter medications and supplies: $[Amount]

Other documented costs (childcare, home help, etc.): $[Amount]

Total Other Injury-Related Expenses: $[Total Other Expenses]

9. Settlement Demand

Considering the clear liability of your insured, the nature and extent of my injuries, my medical treatment and expenses, my lost income, my pain and suffering, and other documented losses, I hereby demand the following amount in full and final settlement of my personal injury claim:

Total Settlement Demand: $[Demand Amount]

This demand is based on:

• Medical expenses: $[Total Medical Bills]

• Lost income: $[Total Lost Wages]

• Other out-of-pocket expenses: $[Total Other Expenses]

• Pain, suffering, and loss of enjoyment of life: $[Non-Economic Damages Component]

Medical expenses: $[Total Medical Bills]

Lost income: $[Total Lost Wages]

Other out-of-pocket expenses: $[Total Other Expenses]

Pain, suffering, and loss of enjoyment of life: $[Non-Economic Damages Component]

10. Response Deadline

Please provide a written response to this settlement demand within [30] days of the date of this letter. You may send your response to me at the address and email listed above, or to my legal representative, if any, at:

[Attorney Name / Law Firm]

[Street Address]

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

[Phone Number]

[Email Address]

11. Reservation of Rights

Nothing in this letter should be interpreted as a waiver of any rights or remedies I may have under applicable law. I reserve the right to supplement, amend, or revise this demand as additional information, medical records, or losses become known.

Sincerely,

[Your Signature]

[Your Printed Name]

12. Enclosures

Enclosures (check or list as applicable):

• Medical records

• Medical bills and statements

• Proof of lost income (pay stubs, employer letter, tax records)

• Receipts for out-of-pocket expenses

• Photographs of injuries or property damage

• Police or incident reports

• Other supporting documents: [Describe]

Medical records

Medical bills and statements

Proof of lost income (pay stubs, employer letter, tax records)

Receipts for out-of-pocket expenses

Photographs of injuries or property damage

Police or incident reports

Other supporting documents: [Describe]