Were you hospitalized? If so, where and for how long?
Period of time
Please state where you are employed and whether you have lost income as a
result of this accident. If you have lost income, please state the amount, and the
date(s) you lost work.
Place of employment:
Hourly wage or salary:
Amount of income lost:
Dates of work lost:
Do you anticipate further loss of wages?
What is your marital status, yearly income, number of dependents, educational
background, job (career potential) and age?
Do you have any insurance policies (automobile, health, accident, disability,
etc)? Please provide us with copies of ALL of your policies.
Address and telephone
Please provide a copy of the policy.