Notice Of Tort Claim (Page 4 of 8) in pdf

Notice Of Tort Claim Page 4

(2) Do you claim permanent disability resulting from this injury?

If yes, describe the injuries believed to be permanent.

(3) For each hospital, doctor, or other practitioner rendering treatment,

examination or diagnostic services, state:

Name of hospital,

Dates of

Amt. of

Amt. Paid or

Doctor, or other Address

treatment

charges

payable by other

Facility

or service

to date

sources such as

Provide copies of all written reports of your attending physicians or dentists setting

forth the nature and extent of injury and treatment, any degree of temporary or

permanent disability, the prognosis, period of hospitalization, and any diminished

earning capacity.

Provide copies of itemized bills for medical, dental, and hospital expenses incurred, or

itemized receipts of payment for such expenses.

If future treatment is necessary, provide a statement of anticipated expenses for each

treatment.

(4) If you claim loss of wages or income as a result of injury, state:

_________________________________

____________________________________

Name of Employer

Address of Employer

_________________________________

____________________________________

Your Occupation

Date You Became Employed

_________________________________

____________________________________

Total Lost Wages to Date

Expected Date of Return (If Out)

NOTE: If your claimed loss of income arises from self-employment or other than

wages, attach a calculation showing the basis of your calculation of lost income.

(5) Set forth any and all other losses or damages claimed by you.

Notice Of Tort Claim Page 4