Vehicle Related Personal Injury
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Vehicle Related Personal Injury
Send original to Personal Injury Liens. Make copy for case record.
Program:
Branch:
Case number: Caseworker name:
Worker phone:
Injured person's prime no.:
Case name:
Branch
PIL
1. Name and address of injured person:
2. Date of injury/accident:
3. Were you employed at time of accident?
Yes
No
Who was your employer:
4. Location/address where injury/accident occurred (include city and state):
5. Did you receive wage loss benefi ts?
Yes Amount: $_________
No
5a. Did you have automobile medical insurance at the time of the accident?
Yes
No
6. Have you fi led a personal injury claim?
Yes
No
6a. Has the claim been settled or resolved?
Yes Amount: $_________
No
Date settled:
7. Were your medical expenses covered by an insurance company other than Medicaid?
Yes
No
Claim number:
Insurance company name:
8. Your attorney's name:
Phone number:
Attorney's address:
9. Were you?
Driver
Passenger
Pedestrian
Bicyclist
10.
Driver's
Vehicle 1: Injured person's vehicle
Vehicle 2: Other vehicle
Name:
Address:
City/State/ZIP:
Phone number:
Driver's insurance co.:
Policy number:
Claim number:
Adjuster's name:
Adjuster's phone:
11.
Owner (if other than driver)
Name:
Address:
City/State/ZIP:
Phone number:
Insurance company:
Policy number:
Claim number:
Adjuster's name:
Adjuster's phone:
MSC 0451 Page 1 of 2 (09/11), can use prior version
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Parent category: Business