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act accordingly. Sincerely, [Insert name] Additionally, my spouse demands damages in the sum of [insert amount] for loss of consortium and loss of service]. If you need further information in to evaluate this claim, please contact me. Please damages: damages to vehicle; medical and prescription bills not covered by your insurer, lost wages, etc.; Non-economic damages: physical pain, mental anguish, physical impairment]. [Optional clause: s]. Due to your insured's negligence, I have suffered emotional and physical harm and hereby demand damages for your insured's negligence in the amount of [insert amount] (Add the following: Economic res that I performed around the house. As newlyweds, we have also stopped being intimate. Prior to accident we were intimate three times a week. After the accident, we no longer engage in intimate actattach proof of absences, if applicable]. [If married include explanation of spouse's contribution to assist you as well as loss of intimidate contact ­ e.g. My spouse, [insert name] has take over choa [insert occupation]. After [insert date of accident], I have been unable to [insert all activities you no longer can engage in]. I have also missed several days of work. See attached documentation [ge]. Prior to the accident, I was able to [insert activities, e.g. bowling three times a week, gardening, clean my house, golfing]. I had no ailments or injuries. I worked [full-time or part-time] as ME OF PHYSICAL THERAPIST [if applicable] On [insert date], I was seen by [insert name] for [insert treatment including number of times as well as any follow-up visits]. INSERT YOUR NAME I am [insert aagain for my injuries due to the accident on [insert date]. [Describe any follow-up diagnosis, treatment, etc.] See attached Medical Records. INSERT NAME OF SECOND PHYSICIAN [if, applicable] INSERT NA He prescribed [insert medication] for pain and to reduce swelling [if applicable]. [NOTE: If pre-existing condition, explain how accident has aggravated condition]. On [insert date], I saw Dr. Smith r. Smith noted that I had [insert injuries] and that I would need [insert treatment, e.g. three weeks of physical therapy]. I indicated to the [insert name of Doctor] that I had [insert type of pain].see [insert follow- up doctor] See attached Emergency Room Medical Report. INSERT NAME OF FIRST PHYSICIAN On [insert date], I saw [insert name of doctor, address] for injuries to [insert injuries]. Dad x-rays of my neck and shoulder. Her diagnosis of my injuries was that I had a sprained shoulder and neck. She prescribed [insert medication] and ordered three days of bed rest. I was instructed to al, if applicable]. See attached police report. [INSERT NAME OF TREATING HOPSITAL] [Describe treatment at hospital], e.g. After being transferred to Bayview Hospital, I was seen by Dr. Ferguson. She heport of the accident cites your insured as being in violation of [insert law]. Subsequently, I was treated by [insert name] for injuries to [insert injuries] and transported to [insert name of hospitng North on Bay Rd. When your insured reached the intersection of 90 and Bay Rd, he failed to observe a stop sign and his vehicle struck my vehicle causing substantial damage to my vehicle. A police r the negligence of your insured, [insert name], on [insert date]. On [insert date] [describe accident] e.g. On February 3, 2004, I was driving west on Interstate 90. Your insured at the time was headie: Their Insured's Name: Their Insured's Policy Number: Date of Accident: Dear [Insert Name of Representative]: This letter is to serve as notification and claim for damages I received as a result ofThird Party Insurer Your name Address Telephone Email SENT VIA [FACSIMILE, ELECTRONIC MAIL, US MAIL, EXPRESS MAIL] [Date] Name of Insurance Co. Representative Name [if available] Address RE: Your Namcharges. Copy of all medical notes or evidence for lost wages, including medical absences notes. Copy and/or pictures of automobile or place of accident. CLAIM FORM FOR AUTOMOBILE ACCIDENT ­ Against ecords, including but not limited to, ambulance report, emergency room and treating physicians report, if possible a physician narrative. Copy of all bills, including medical bills and pharmaceutical documents: Name of owner of liable vehicle, owner's insurance company, address, policy number and name of negligent driver, if not the owner. Copy of automobile accident report. Copy of all medical rg any document with another party. The purchase and use of this form is subject to the "Terms and Conditions" found at www.FindLegalForms.com Prior to completing, individuals should have the followingnot a substitute for legal advice. This form should only be a starting point for you and should not be used without first consulting with an attorney. An attorney should be consulted before negotiatinInformation Claim Form for Auto Accident Bracketed instructions have been included on this form to assist you in completing it and should be removed before printing. This form is not intended and is