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um and loss of service]. If you need further information in to evaluate this claim, please contact me. Please act accordingly. Sincerely, [Insert name] ost wages, etc.; Non-economic damages: physical pain, mental anguish, physical impairment]. [Optional clause: Additionally, my spouse demands damages in the sum of [insert amount] for loss of consortiysical harm and hereby demand damages for your insured's negligence in the amount of [insert amount] (Add the following: Economic damages: medical and prescription bills not covered by your insurer, led being intimate. Prior to accident we were intimate three times a week. After the accident, we no longer engage in intimate acts]. Due to your business's negligence, I have suffered emotional and phtion of spouse's contribution to assist you as well as loss of intimate contact ­ e.g. My spouse, [insert name] has take over chores that I performed around the house. As newlyweds, we have also stoppnable to [insert all activities you no longer can engage in]. I have also missed several days of work. See attached documentation [attach proof of absences, if applicable]. [If married include explanathree times a week, gardening, clean my house, golfing, etc.]. I had no ailments or injuries. I worked [full-time or part-time] as a [insert occupation]. After [insert date of incident], I have been uT NAME OF SECOND PHYSICIAN [if, applicable] INSERT NAME OF PHYSICAL THERAPIST [if applicable] INSERT YOUR NAME I am [insert age]. Prior to the injuries, I was able to [insert activities, e.g. bowling He prescribed [insert medication] for pain and to reduce swelling [if applicable]. [NOTE: If pre-existing condition, explain how accident has aggravated condition]. See attached Medical Records. INSER. 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]. . Ferguson, I scheduled a follow-up treatment with Dr. Smith, located at 777 Sixth Ave, Sunnytown, State. On [insert date], I saw [insert name of doctor, address] for injuries to [insert injuries]. Dr x-rays of my cracked left molar. She indicated that the damage to the tooth required root canal. See attached report. INSERT NAME OF FIRST PHYSICIAN AFTER TREATING HOSPITAL Per the instructions of Drnd ordered three days of bed rest. I was instructed to see [insert follow- up doctor]. See attached Emergency Room Medical Report. [OR] At my scheduled appointment on February 4, 2005, Dr. Smith tookof my injuries was that I had several deep abrasions to my tongue and throat and advised me to maintain a liquid diet for several days. She also prescribed [insert medication] for infection and pain aERT NAME OF TREATING HOPSITAL OR FIRST PHYSICIAN/DENTIST] [Describe treatment], e.g. After being transferred to Bayview Hospital, I was seen by Dr. Ferguson. She had x-rays of my mouth. Her diagnosis formed the manager, Tom Smith, who apologized and called 911 for an ambulance. Paramedics from Sunnytown arrived and transported me to Bayview Hospital located at 54 West Ave., Sunnytown, State.] [INSWhile dining, I ordered a cheesecake for dessert. When I bit into the cheesecake, I felt crunching in my mouth and immediately spit out the bite and noticed several pieces of glass. At said time, I ino instructed me not to eat on that side of the mouth and arranged for me to come into her office the next day. [OR] On February 3, 2004, I went to your restaurant at XYZ location in Sunnytown, State. urchased a pound cake from XYZ supermarket. On or about February 4, 2004, while eating said pound cake I bit into a hard substance causing my back molar to crack. I immediately contacted my dentist whss' negligence, I suffered physical and emotional damages to which your negligence was the actual and proximate cause of my injuries. On [insert date] [describe incident (e.g. On February 3, 2004, I pr is to serve as notification and claim for damages for injuries that occurred while I was eating [describe type of food] that I purchased at [insert name of location or restaurant] Due to your busineame of Business Attention: Registered Agent [if available] Address RE: Injury From [Insert type of Foreign Object] [Purchased at [Insert Name of Store] or [Restaurant]] Dear [Insert Name]: This lettesion of object. CLAIM FORM FOR FOREIGN OBJECT IN FOOD Your name Address Telephone Email SENT VIA [FACSIMILE, ELECTRONIC MAIL, US MAIL, EXPRESS MAIL or CERTIFIED MAIL, preferable for records] [Date] NCopy of all bills, including medical bills and pharmaceutical charges. Copy of all medical notes or evidence for lost wages, including medical absences notes. Pictures of foreign object. Retain possesees and other witnesses to the incident. Copy of all medical records, including but not limited to, ambulance report, emergency room and treating physicians report, if possible a physician narrative. ollowing documents: Name of business, if corporation send to registered agent listed with Department of State, business address. Copy of Business Accident Report, if available. List of business employgotiating 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 f and is not 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 neInformation Claim Form for Foreign Object in Food 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