This Claim Form for Foreign Object in Food is for use by an individual who has received injuries from eating food containing a foreign object. It can also be used by an attorney representing a client who has suffered this type of injury. This claim form is a formal notice which informs a restaurant or grocery that food purchased at their location contained an unknown object. This letter format claim form contains the pertinent information regarding the injury including where the injury occurred, where treatment was received and names of treating physicians. It also includes a short description of the injured party and how this injury has affected their life and livelihood. It is imperative that the particulars regarding this type of injury be memorialized in writing. A written Claim Form after eating food containing a foreign object will act as formal notice of the claim and be useful in the event litigation is filed.

This Claim Form – Foreign Object in Food includes the following:

• Business/Registered Agent: Sets out the name and address of the business where the injury occurred and sent to the registered agent if the business is a corporation;
• Injury: Sets out a detailed description of the incident including date, type of food and the location of the business or restaurant;
• Treating Hospital/Physician or Dentist: Sets out a description of treatment received, name of attending physician or dentist, medications prescribed and follow-up instructions;
• Follow-Up Treatment: Sets out any follow-up doctor or dental visits necessitated by the injury and if injury was pre-existing, how the injury aggravated this condition;
• Description of Injured Party: A short synopsis regarding how the injury has changed the injured party’s life (absence from work, inability to perform household chores and economic hardships);
• Demand for Damages: A demand for damages including payment for lost wages, medical expenses and mental anguish;
• Signature: The claim form must be signed by the attorney or individual who suffered the injury.

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This attorney-prepared packet contains:

1. General Information and Checklist
2. Claim Form – Foreign Object in Food

State Law Compliance: This form complies with the laws of all states