Application For Benefits - Personal Injury Protection Page 2
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3DESCRIBE YO UR INJURY:
W ERE YOU TREATED BY A DOCTOR:
YES
NO
DO CTO R’S NAME AND ADDRESS:
IF YOU W ERE TREATED IN A HOSPITAL W ERE YOU AN
IN-PATIENT
OUT-PATIENT
HO SPITAL’S NAME AND ADDRESS:
AMO UNT O F MEDICAL BILLS TO DATE: $
W ILL YOU HAVE MORE MEDICAL EXPENSES?
YES
NO
AT TIME OF YO U ACCIDENT W ERE YO U IN THE
CO URSE O F YO UR EMPLO YMENT?
YES
NO
DID YOU LOSE W AG ES O R SALARY AS RESULT
OF YOUR INJURY?
YES
NO
IF YES, AMO UNT TO DATE:
W HAT IS YOUR AVERAGE W EEKLY W AGE/SALARY?
IF YO U LO ST W AG ES, DATE DISABILITY FRO M W O RK BEG AN:
DATE YO U RETURNED TO W O RK:
HAVE YOU RECEIVED OR ARE YOU ELIGIBLE FOR BENEFITS UNDER:
W ORKMEN’S COMPENSATION LAW S?
YES
NO
SOCIAL SECURITY BENEFITS?
YES
NO
IF YOU ARE CLAIMING LOST W AGES, COMPLETE THIS SECTION, DOING SO W ILL HELP US PROMPTLY VERIFY YOUR SALARY
RATE W ITH YOUR EMPLOYER.
EMPLO YER AND ADDRESS
O CCUPATIO N
FROM
TO
EMPLO YER AND ADDRESS
O CCUPATIO N
FROM
TO
HAVE YO U HAD ANY OTHER EXPENSES AS A RESULT OF YOU INJURY? YES
NO
IF YES, EXPLAIN:
I hereby authorize release of m edical inform ation, including but not lim ited to m edical bills and reports, to such persons as the com pany m ay
deem s necessary.
Signature
Date
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Parent category: Legal