Fill and Sign the Personal Injury Report Form

PERSONAL INJURY PROGRESS REPORT File Name File Number Date of Report Defendant’s Liability Insurance Coverage Name of Carrier Address of Carrier Name of Adjustor Telephone Number Amount of Coverage $ Plaintiff’s Insurance Coverage Name of Carrier Address of Carrier Name of Adjustor Telephone Number Amount of Medical Payments Coverage $ Amount of UM/UIM Coverage $ Medical Care Providers Name of Carrier Address of Carrier Telephone Number Name of Carrier Address of Carrier Telephone Number Name of Carrier Address of Carrier Telephone Number Name of Carrier Address of Carrier Telephone Number - 1 - Bills/Records Requested from Date Bills/Records Requested Date Bills Received Date Records Received Bills/Records Requested from Date Bills/Records Requested Date Bills Received Date Records Received Bills/Records Requested from Date Bills/Records Requested Date Bills Received Date Records Received Bills/Records Requested from Date Bills/Records Requested Date Bills Received Date Records Received Bills/Records Requested from Date Bills/Records Requested Date Bills Received Date Records Received Bills/Records Requested from Date Bills/Records Requested Date Bills Received Date Records Received Bills/Records Requested from Date Bills/Records Requested Date Bills Received Date Records Received Bills/Records Requested from Date Bills/Records Requested Date Bills Received Date Records Received - 2 - Subrogation Claims and Letters of Protection 1 . 2 . 3 . 4 . 5 . Summary Injuries 1 . 2 . 3 . 4 . 5 . Summary of Treatment 1 . 2 . 3 . 4 . 5 . Prior Injuries Description Date 1 . - 3 - 2 . 3 . 4 . 5 . Police Report Date Requested Date Received Liability Other Findings Property Damage Description Cost of Repair $ Lost Wages Days Missed from Work Daily Rate of Pay $ per TOTAL $ Other Significant Information To Do List 1. - 4 - 2. 3. 4. 5. 6. 7. 8. 9. 10 . - 5 -