Legal Claimant Form

LEGAL CLAIMANT FORM

This Legal Claimant Form is made and entered into by and between Claimant Name: and Respondent Name: (each a "Party" and together the "Parties") on Submission Date: .

RECITALS

WHEREAS, Claimant asserts a legal claim arising from the events, facts, or transactions described in this Form and seeks to provide notice and supporting documentation to Respondent for evaluation and potential resolution; and

WHEREAS, Respondent is the entity or individual against whom the Claimant asserts a claim, and Respondent may investigate, respond, or engage in settlement discussions consistent with the terms of this Form; and

WHEREAS, the Parties desire to record essential claim information, certifications, authorizations, and the procedural rights applicable to the claim as set forth below.

NOW THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows:

1. CLAIM IDENTIFICATION

Month:    Day:    Year:

2. CLAIMANT INFORMATION

Individual    Corporation    Partnership    Other

3. CLAIM DETAILS

4. SUPPORTING DOCUMENTATION

Attachments provided with this Form (check all that apply):

Photographs    Contracts/Agreements    Invoices/Receipts    Medical Records    Other

5. REPRESENTATIONS AND WARRANTIES

Claimant represents and warrants that Claimant is authorized to submit this claim, that the statements and information contained herein are true, correct and complete to the best of Claimant's knowledge, and that Claimant has not knowingly withheld material facts. Claimant further warrants that any documents provided as attachments are genuine copies of originals in Claimant's possession or control.

Claimant acknowledges that making false statements in connection with this claim may subject Claimant to civil liability, criminal penalties, and forfeiture of any claim asserted herein.

6. AUTHORIZATION TO INVESTIGATE

By submitting this Form, Claimant expressly authorizes Respondent and its agents to investigate, request, and obtain relevant records and information from third parties, including but not limited to medical providers, insurers, employers, and witnesses, solely for the purposes of evaluating the claim. Claimant understands that such investigation may include verification of facts, background checks, and review of documents.

7. CONFIDENTIALITY AND DISCLOSURE

Subject to applicable law, communications, documents and information exchanged in connection with this claim may be treated as confidential by the Parties. Nothing in this section shall prevent disclosure when required by statute, court order, or lawful government request, nor shall it limit a Party's right to disclose information in connection with legal proceedings necessary to enforce rights related to this claim.

8. REMEDIES REQUESTED

9. NOTICES

All notices required or permitted under this Form shall be in writing and delivered to the addresses provided below by hand delivery, nationally recognized overnight courier, or certified mail, return receipt requested, and shall be deemed given upon receipt.

10. GOVERNING LAW; VENUE

This Form shall be governed by and construed in accordance with the substantive laws of the state identified below, without regard to conflict of laws principles. The Parties submit to exclusive jurisdiction and venue in the courts located in the county specified below for any dispute arising out of or relating to this Form.

11. ENTIRE AGREEMENT; SEVERABILITY

This Form embodies the entire understanding of the Parties with respect to its subject matter and supersedes all prior and contemporaneous agreements, negotiations and understandings, whether written or oral. If any provision of this Form is determined to be invalid, illegal or unenforceable, such determination shall not affect the validity or enforceability of any other provision, which shall remain in full force and effect.

12. AMENDMENT; WAIVER; COUNTERPARTS

This Form may be amended only by a written instrument signed by both Parties. No failure or delay by a Party in exercising any right shall operate as a waiver thereof, and no single or partial exercise of any right shall preclude any other or further exercise. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

13. CERTIFICATION

By signing below, Claimant certifies under penalty of perjury that the information contained in this Form and the attached documents is true, correct and complete to the best of Claimant's knowledge, information, and belief. Claimant acknowledges that Respondent may rely on these representations in evaluating, processing, or defending against the claim.

I affirm the foregoing certification and understand the legal consequences of making false statements.

14. ADDITIONAL INFORMATION

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