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CLAIM QUESTIONNAIRE
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Please take the time to fill this form out as completely as possible.
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Name:
*
Date:
*
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Email:
*
Phone:
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1)
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Please list any wage loss you may have experienced as a result of this accident.
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Dates off work:
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Salary:
Number of hours worked per week:
Total wage loss:
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2)
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Please list, in order, all medical providers you have visited for services relating to the accident and estimate the distance you traveled round trip to visit those providers.
(Please provide both facility and provider name)
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3)
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To the best of your ability, please list all medical providers you have ever visited for the same or similar injuries within 5 years of your current injury accident.
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4)
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Do you feel that your injury will be permanent or that you will need further medical services?
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If yes, please explain:
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5)
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Please list and discuss ways in which the accident has affected your life. Compare your activities before the accident with your ability to perform the same activities after the accident. Consider your hobbies, family, social, household, work, and other activities.
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BEFORE
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AFTER
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i.e. Sleep OK, Play with children, No problems kneeling
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Problems sleeping, Can't pick up kids, Can't kneel
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6)
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Please describe the physical pain and mental suffering and inconvenience you have endured since the accident
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7)
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Please discuss any humiliation you have experienced as a result of this accident. (i.e. had to wear a brace at graduation)
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8)
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Please list any other information you are concerned about that is not listed on this form.
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