Accident Information

In your own words, please briefly describe the accident/injury:

What were your injuries:

Who did you report the injury to:

Have you returned to work: Yes No   If so, what date: / /

If not, have you received benefits in the form of payments for being unable to work?
Yes No

If you have, what amount $
How often are you receiving benefits?

Medical Information

Please list all medical providers you have seen as a result of this accident/injury below:

Medical Care Provider	City & State Provider Resides

Have you had surgery as a result of this injury/accident? Yes No

If so, at what facility? Date of Surgery: / /

Please list the medical care providers you have seen previous to this accident/injury within the past ten (10) years below:

Medical Care Provider	City & State Provider Resides

What injuries still effect you (continuing symptoms)?

Loss of Income

Are you claiming a loss of income as a result of this accident/injury? Yes No

If yes, please provide information as to the following:

Dates missed from work:

Wage per hour: or Salary per month:

With regard to missed hours, did you:

Receive a reduction in pay for missed time; Use vacation time;
Use sick time; or Use paid time off (PTO)

Explanation if necessary

Clark and Feeney will need a statement from your employer as to missed time from work for a claim in lost wages.

Changes in Lifestyle

Please describe in detail the activities you performed prior to the subject accident that you are no longer able to perform:

Please describe in detail how your injuries have changed your life:

With regard to missed hours, did you:

Receive a reduction in pay for missed time; Use vacation time;
Use sick time; or Use paid time off (PTO)

Explanation if necessary

Clark and Feeney will need a statement from your employer as to missed time from work for a claim in lost wages.