Legal Injury Claim Form

LEGAL INJURY CLAIM FORM

This Legal Injury Claim Form (the "Claim") is made and entered into as of Effective Date: by and between Claimant Name: whose address is and Respondent Name: whose address is .

RECITALS

WHEREAS, on or about Date of Incident: at Location of Incident: , Claimant alleges that Claimant sustained bodily injury and property damage arising out of the incident described herein (the "Incident").

WHEREAS, Claimant has received or sought medical treatment for injuries arising from the Incident and intends to present claims for medical expenses, lost earnings, pain and suffering, and related damages.

WHEREAS, Respondent acknowledges receipt of this Claim and agrees to review documentation submitted by Claimant in accordance with the terms set forth below; nothing in this Claim shall be construed as an admission of liability by Respondent unless expressly stated in a signed settlement agreement.

NOW THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

1. DEFINITIONS

For purposes of this Claim, the following definitions apply: "Claimant" means the person identified above as Claimant; "Respondent" means the person or entity identified above as Respondent; "Incident" means the event described in the Recitals; "Claim Amount" means the monetary amount asserted by Claimant in Section 2. Capitalized terms used but not defined herein shall have the meanings ascribed to them in common legal usage.

2. CLAIM DETAILS

2.1 Claim Amount (itemized below): Claim Amount: $

2.8 Police report filed: Yes    Report Number:

3. AUTHORIZATION TO OBTAIN RECORDS

Claimant hereby authorizes any and all medical providers, employers, and other custodians of records to disclose and release medical, employment, billing, and related records reasonably necessary to substantiate the Claim to Respondent or Respondent's authorized representatives. This authorization includes mental health and substance abuse records to the extent required to evaluate treatment related to the Incident. The authorization remains effective for the period commencing on the Effective Date and continuing for a period of unless revoked in writing.

Claimant acknowledges that a photocopy or electronic copy of this authorization shall be as valid as the original.

4. REPRESENTATIONS, WARRANTIES AND CERTIFICATIONS

Claimant represents and warrants that: (a) the statements and information provided in this Claim are true, complete, and correct to the best of Claimant's knowledge; (b) Claimant has not previously released or assigned any portion of the Claim except as disclosed in writing; (c) Claimant will cooperate in the reasonable investigation of the Claim and provide additional documentation upon request; and (d) Claimant understands that knowingly submitting materially false information in support of a claim may subject Claimant to civil or criminal penalties under applicable law.

5. EVIDENCE AND DOCUMENTATION

Claimant shall provide, attach, or make available upon request copies of all documentation supporting the Claim, including but not limited to medical records, itemized medical bills, receipts, wage statements, photographs, repair estimates, and police reports. Failure to provide requested documentation may result in delay or denial of the Claim.

6. CONFIDENTIALITY AND RESERVATION OF RIGHTS

Submission of this Claim and any accompanying documents is for the purpose of claim evaluation and settlement discussions. Such submission shall not constitute an admission of liability by Respondent. Respondent expressly reserves all defenses, statutory and common law rights, and objections available to it, including but not limited to defenses based on causation, comparative negligence, mitigation, statutes of limitation, and notice requirements.

7. NOTICES

All notices required or permitted under this Claim shall be in writing and delivered personally, by certified mail, return receipt requested, or by nationally recognized overnight courier to the addresses set forth below or to such other address as a party may designate by written notice.

8. AMENDMENTS, WAIVER, COUNTERPARTS

This Claim may be amended only by a written instrument signed by both parties. No waiver of any provision of this Claim shall be effective unless in writing and signed by the party against whom enforcement is sought. This Claim may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. Signatures transmitted by electronic means shall be binding.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Claim shall be governed by and construed in accordance with the substantive laws of the state whose law governs disputes arising out of the Incident as elected by mutual agreement of the parties. This Claim constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, understandings, and agreements. If any provision of this Claim is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

10. SIGNATORY CERTIFICATION

By signing below, each signatory certifies under penalty of perjury that the information provided in this Claim is true and correct to the best of the signatory's knowledge, that the signatory is authorized to submit and sign on behalf of the party identified, and that the signatory has read and understands the terms of this Claim.

WARNING: Knowingly submitting a materially false or fraudulent claim may subject the claimant to civil or criminal penalties under applicable law.

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