Personal Injury Claim Application

PERSONAL INJURY CLAIM APPLICATION

This Personal Injury Claim Application is submitted by Applicant Name: (hereinafter "Claimant") against Respondent Name: (hereinafter "Respondent/Insurer"). Application Date:

RECITALS

WHEREAS, on or about the date and time set forth below, Claimant alleges that Claimant sustained bodily injury and/or property damage as a proximate result of an incident involving Respondent or a person or entity for whom Respondent may be liable; and

WHEREAS, Claimant seeks to provide complete factual, medical and financial information to permit investigation, adjustment and resolution of the asserted claim; and

WHEREAS, Respondent (or Respondent's insurer) requires completion of this application as part of the claims intake, investigation and evaluation process.

NOW, THEREFORE, in consideration of the parties' mutual covenants and for other good and valuable consideration, Claimant submits the following information under penalty of perjury as true and correct to the best of Claimant's knowledge.

1. DEFINITIONS

For purposes of this Application, "Claimant" refers to the individual identified above; "Respondent" refers to the individual, business or insurer identified above; "Incident" refers to the occurrence described in Section 3 below.

2. CLAIMANT INFORMATION

3. INCIDENT DETAILS

Date of Incident:    Time of Incident:

4. INJURIES AND MEDICAL TREATMENT

Hospitalized? Yes No

5. EMPLOYMENT, EARNINGS AND LOSS

6. PROPERTY DAMAGE (IF APPLICABLE)

7. INSURANCE AND LIABILITY INFORMATION

8. WITNESSES

9. AUTHORIZATION FOR RELEASE OF RECORDS

Claimant hereby authorizes any and all medical providers, hospitals, clinics, physicians, insurers, employers and other custodians of records to release to Respondent, Respondent's insurers and their authorized representatives all medical records, billing information, employment records and other documents reasonably relevant to the Incident and any claimed injuries. Claimant understands that such records may include mental health, substance use disorder and HIV-related information where applicable and expressly consents to release of such records to the extent necessary for claim evaluation. This authorization is valid for the duration necessary to process and resolve the claim.

Claimant further authorizes Respondent, Respondent's insurer or their representatives to obtain medical summaries and billing records directly from providers, and to furnish copies of this Application and medical records to attorneys or third parties engaged to evaluate or defend the claim.

10. CERTIFICATION, REPRESENTATIONS AND WARRANTIES

Claimant certifies under penalty of perjury that the information provided in this Application is true, correct and complete to the best of Claimant's knowledge. Claimant understands that material misrepresentations or omissions may be grounds for denial of benefits or termination of any settlement and may subject Claimant to civil or criminal penalties.

Claimant understands that submission of this Application does not constitute an admission of liability by Respondent, nor does it create any contractual obligation to settle or pay unless and until a written agreement is executed by authorized representatives of the parties.

Claimant authorizes Respondent or Claimant's representative to pursue settlement or recovery on Claimant's behalf.

11. NOTICES

Notices required by this Application shall be effective upon receipt when delivered in person, by certified mail, or by nationally recognized overnight courier to the addresses provided above or to such other address as a party designates in writing.

12. MISCELLANEOUS PROVISIONS

Governing Law: This Application and any dispute arising out of or relating to it shall be governed by and construed in accordance with the laws of the state specified by the parties' agreement or, absent agreement, the laws of the state in which the Incident occurred, without regard to conflict of laws principles.

Entire Agreement: This Application, together with any mutually executed written agreements, constitutes the entire understanding of the parties with respect to the subject matter herein and supersedes all prior negotiations, understandings and representations.

Severability: If any provision of this Application is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

Amendments and Waiver: No amendment or waiver of any provision of this Application will be effective unless in writing and signed by both parties. The failure of either party to enforce any provision will not constitute a waiver of future enforcement of that or any other provision.

Counterparts: This Application may be executed in counterparts, each of which will be deemed an original, and all of which together will constitute one and the same instrument. Electronic or facsimile signatures shall have the same force and effect as original signatures.

13. FINAL DECLARATION

By signing below, the parties certify that they have read and understood this Personal Injury Claim Application, that the facts set forth are true and complete to the best of their knowledge, and that they are authorized to provide the information and execute this document on behalf of the identified parties.

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