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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 act accordingly. Sincerely, [Insert name] on bills not covered by your insurer, lost wages, etc.; Non-economic damages: physical pain, mental anguish, physical impairment]. [Optional clause: Additionally, my spouse demands damages in the sum gence, 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 damages: medical and prescriptihouse. 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 acts]. Due to your business's negliplicable]. [If married include explanation of spouse's contribution to assist you as well as loss of intimate contact ­ e.g. My spouse, [insert name] has taken over chores that I performed around the nsert 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 [attach proof of absences, if ape to [insert activities, e.g. bowling three 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 [in [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 age]. Prior to the slip and fall, I was ablon [insert date]. [Describe any follow-up diagnosis, treatment, etc.] See attached Medical Records. INSERT NAME OF SECOND PHYSICIAN [if, applicable] INSERT NAME OF PHYSICAL THERAPIST [if applicable] O to reduce swelling [if applicable]. [NOTE: If pre-existing condition, explain how accident has aggravated condition]. On [insert date], I saw Dr. Smith again for my injuries due to the slip and fall 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]. He prescribed [insert medication] for pain andergency Room Medical Report. INSERT NAME OF FIRST PHYSICIAN On [insert date], I saw [insert name of doctor, address] for injuries to [insert injuries]. Dr. Smith noted that I had [insert injuries] and 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 see [insert follow- up doctor]. See attached EmATING HOPSITAL OR FIRST PHYSICIAN] [Describe treatment at hospital], e.g. After being transferred to Bayview Hospital, I was seen by Dr. Ferguson. She had x-rays of my neck and shoulder. Her diagnosis from accident, indicate first treatment--e.g. After leaving the store, I experienced pain in my upper and lower back and sought treatment on February 10, 2004 at Bayview Hospital. [INSERT NAME OF TREad accumulated due to a known roof leak. Subsequently, I was transported to [insert name of hospital, if applicable]. See attached business accident report and/or ambulance report. [If not transportedtance and upon learning that I was unable to stand, called an ambulance. While waiting for the ambulance, the manager of the store, Mr. Thomas Ward, explained to me that the substance was water that hocated at 24 Third Street in Madison, California. While entering your business, I slipped on a substance causing me to fall backwards onto my back. An employee named, Ms. Carol Smith, came to my assissical 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 was shopping at your business ld at [insert address of business] on [insert date]. Due to your business's failure to inspect, maintain and adequately warn [state negligent act ­ e.g. failure to clean water on floor], I suffered phye address] on [Insert Date of Accident] Dear [Insert Name]: This letter is to serve as notification and claim for damages for a slip and fall that occurred while I was shopping at your business locateIC MAIL, US MAIL, EXPRESS MAIL or CERTIFIED MAIL, preferable for records] [Date] Name of Business Attention: Registered Agent [if available] Address RE: Slip and Fall at [Name of Business and completces notes. Copy and/or pictures of place of accident and self, if physical injuries. CLAIM FORM FOR SLIP AND FALL ­ Commercial Property Your name Address Telephone Email SENT VIA [FACSIMILE, ELECTRONysicians report, if possible a physician narrative. Copy of all bills, including medical bills and pharmaceutical charges. Copy of all medical notes or evidence for lost wages, including medical abseniness employees who were witnesses to the accident, including store manager (if applicable). Copy of all medical records, including but not limited to, ambulance report, emergency room and treating phd have the following 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 bused before negotiating 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 shoulnot intended 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 consultInformation Claim Form for Slip & Fall (Commercial Property) Bracketed instructions have been included on this form to assist you in completing it and should be removed before printing. This form is