Proof of Injury Form Template

Proof of Injury Form Template

[Organization / Insurance Company / Employer Name]
[Department, if applicable]
[Street Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Email: [Email Address]

1. Injured Person 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. Claim, Case, or Policy Information

Type of Matter (check or describe):

• Motor vehicle accident (may include DUI-related)

• Workplace injury

• Slip-and-fall / premises incident

• Sports or recreational injury

• Assault or intentional harm

• Other personal injury: [Describe]

Insurance Company (if applicable): [Name]
Policy Number: [Number]
Claim Number (if assigned): [Number]

Employer (if work-related): [Employer Name]
Job Title: [Job Title]
Employee / ID Number (if any): [Number]

3. Date, Time, and Location of Injury

Date of Injury: [MM/DD/YYYY]
Approximate Time of Injury: [HH:MM a.m./p.m.]

Location of Injury (address or specific place):
[Street address, facility/business name, school, field, job site, etc.]

City: [City]
State/Province: [State/Province]
Country: [Country]

Setting (check one):

• Workplace or job site

• Public place or business

• Private residence

• School, sports facility, or recreational area

• Roadway, sidewalk, or parking lot

• Other: [Describe]

4. Description of Incident (What Happened)

In your own words, describe what you were doing just before the injury occurred (for example, “walking down stairs,” “driving northbound on [Street],” “playing in a soccer match,” “working on a ladder”):

[Free-text description]

Describe step by step how the incident occurred. Focus on facts, not opinions or blame. Include:

• Any hazards or conditions you noticed (wet floor, uneven surface, defective equipment, speeding vehicle, etc.)

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

• How your body moved or made contact with the ground, object, or vehicle

Incident Narrative:
[Free-text narrative]

5. Injured Body Parts and Symptoms

List all parts of your body that were injured as a result of this incident:

[Example: neck, lower back, right shoulder, left knee, right wrist, head, etc.]

Type of Injuries (check all that apply and briefly describe):

• Bruise / contusion – [Description]

• Cut / laceration – [Description]

• Abrasion / scrape – [Description]

• Sprain / strain / whiplash – [Description]

• Suspected fracture / fracture – [Description]

• Dislocation – [Description]

• Concussion / head injury – [Description]

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

• Burn (thermal, chemical, or electrical) – [Description]

• Other: [Describe]

Immediate Symptoms After the Injury (check and describe):

• Pain – [Where and how did it feel?]

• Swelling – [Where?]

• Redness or bruising – [Where?]

• Dizziness or lightheadedness – [Describe]

• Headache – [Describe]

• Nausea or vomiting – [Describe]

• Numbness or tingling – [Where?]

• Weakness – [Where?]

• Other: [Describe]

Current Symptoms (at the time of filling out this form):
[Free-text description]

Pain Level (0–10; 0 = no pain, 10 = worst pain imaginable):
Average daily pain: [0–10]
Worst pain episodes: [0–10]

6. Medical Treatment Information

6.1 Initial Treatment

Did you receive any treatment at the scene?

• No

• Yes – Describe (first aid, EMS assessment, etc.): [Description]

Did you go to a medical facility immediately after the injury?

• Yes

• No

If Yes, complete:

First Facility Visited (name and type):
[Hospital, emergency room, urgent care, clinic, school nurse, occupational health, etc.]

Facility Name: [Name]
City / State/Province: [City, State/Province]
Date of Visit: [MM/DD/YYYY]

Brief summary of initial treatment (for example, “X-rays taken, diagnosed with sprain, given brace and medications,” “wound cleaned and sutured”):
[Free-text]

6.2 Ongoing Treatment

List all doctors, clinics, therapists, or other providers you have seen for this injury.

Provider 1:
Name: [Name]
Specialty (e.g., primary care, orthopedics, physical therapy, chiropractic): [Specialty]
Facility Name: [Facility]
City / State/Province: [City, State/Province]
First Visit Date: [MM/DD/YYYY]
Most Recent Visit Date: [MM/DD/YYYY]

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

[Add additional providers as needed.]

Treatments Received (check all that apply and briefly describe):

• Physical examination and advice – [Description]

• X-rays – [Body part(s) imaged]

• MRI / CT scan / other imaging – [Body part(s) imaged]

• Laboratory tests – [Type, if relevant]

• Prescription medications – [General description]

• Over-the-counter medications – [General description]

• Physical therapy / rehabilitation – [Number of sessions / frequency]

• Chiropractic care – [Frequency]

• Injections (e.g., steroid, pain management) – [Where and when]

• Surgery or procedure – [Type and date]

• Counseling or psychological support – [Brief description]

• Other: [Describe]

7. Work, School, and Activity Limitations

Employment / School Status at Time of Injury:

• Employed full-time

• Employed part-time

• Self-employed

• Independent contractor

• Unemployed

• Student

• Other: [Describe]

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

Have you missed work or school because of this injury?

• Yes

• No

If Yes:

Dates absent: From [MM/DD/YYYY] to [MM/DD/YYYY or “Ongoing”]
Approximate number of full days missed: [Number]
Approximate number of partial days (left early or arrived late): [Number]

Have your hours, duties, or pay changed because of your injury?

• Yes – describe: [Description]

• No

List any written activity or work restrictions given by your doctor (for example, “no lifting over 10 lbs,” “no standing more than 30 minutes,” “no driving,” “light duty only”):
[Free-text]

Daily Activities Affected (check all that apply and briefly describe):

• Walking or standing – [Description]

• Sitting for long periods – [Description]

• Lifting, carrying, or bending – [Description]

• Household tasks (cleaning, cooking, laundry) – [Description]

• Sports, exercise, or hobbies – [Description]

• Caring for children, family, or pets – [Description]

• Sleep or rest – [Description]

• Other: [Describe]

8. Expenses and Supporting Documents (High-Level Summary)

Have you incurred medical or injury-related expenses because of this incident?

• Yes

• No

If Yes, check all that apply and briefly describe:

• Medical bills (hospital, doctor, therapy): [Short summary]

• Prescription medications: [Short summary]

• Over-the-counter medications or supplies: [Short summary]

• Medical equipment (braces, crutches, etc.): [Short summary]

• Transportation to medical appointments: [Short summary]

• Other: [Describe]

Documents you can attach or provide (check all that apply):

• Medical records or visit summaries

• Medical bills and statements

• Pharmacy receipts

• Work status notes or doctor’s letters

• Employer letter confirming missed work or modified duty

• Photos of visible injuries

• Other relevant documents: [Describe]

9. Prior Injuries or Conditions (If Relevant)

Before this incident, did you ever injure the same body part(s) or have similar symptoms?

• Yes

• No

If Yes, briefly describe the prior condition or injury, approximate dates, and whether you had recovered or were stable before this incident:
[Free-text]

10. Authorization and Declaration – Injured Person

I, [Full Name of Injured Person or Legal Guardian], declare that the information provided in this Proof of Injury Form is true and complete to the best of my knowledge and recollection. I understand that this form may be used by insurers, employers, schools, or other organizations to evaluate my claim or request.

I understand that this form does not, by itself, determine eligibility for benefits, legal responsibility, or compensation. I may wish to consult a licensed attorney, doctor, or other qualified professional about my rights and options.

Signature of Injured Person (or Parent/Guardian): _______________________________
Printed Name: [Full Name]
Date Signed: [MM/DD/YYYY]

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

11. Medical Provider Certification (If Required)

To be completed by a licensed healthcare provider, if requested by the insurer or organization.

Provider Name: [Full Name]
Professional Title / Credentials: [MD / DO / NP / PA / Other]
Specialty: [Specialty]

Facility Name: [Clinic / Hospital / Practice]
Address: [Street Address, City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Fax: [Fax Number]

Date of Initial Examination for This Injury: [MM/DD/YYYY]
Most Recent Examination Date: [MM/DD/YYYY]

Working Diagnosis / Diagnoses related to this incident:

1. [Diagnosis 1]

2. [Diagnosis 2]

3. [Diagnosis 3]

In your professional opinion, are the above injuries consistent with the described incident?

• Yes

• No

• Cannot determine based on available information

Current Treatment Plan and Recommended Restrictions (if any):
[Brief description of treatment, expected duration, and work/activity restrictions.]

Additional Comments (optional, within your professional scope):
[Free-text]

I certify that the information in this section is accurate to the best of my knowledge based on my examination and records.

Provider Signature: _______________________________
Printed Name: [Provider Name]
License Number: [Number]
Licensing State/Province: [State/Province]
Date Signed: [MM/DD/YYYY]