statement of claim for bodily injury _ property damage - Florida ...-ag

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					                                           STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION                                        225-085-03
                                                                                                                         GENERAL COUNSEL
                                          STATEMENT OF CLAIM                                                                         06/11
                                                                                                                                Page 1 of 2
                                 FOR BODILY INJURY & PROPERTY DAMAGE
Office of the General Counsel, Department of Transportation, 605 Suwannee Street, MS 58, Tallahassee, FL 32399-0458
                                           dotclaims.review@dot.state.fl.us

                                                                FILE NO.
                                                                                                 (do not complete)
                      Date:                    Time:                   Location:
    ACCIDENT          Type of Claim:         Bodily Injury                               Property Damage
                      Description:
                      Name:                                                                                  Age:
                      Address:                                                   City:                          State:
                      E-Mail (Optional):

INJURED PERSON        Phone No.: (Home)                           (Work)                            (Cell)
                      Occupation and Employer:
                      Why on Premises:
                      Nature and Extent of Injury:

                      Name:                                                                                  Age:
                      Address:                                                   City:                          State:
                      E-Mail (Optional):

INJURED PERSON        Phone No.: (Home)                           (Work)                            (Cell)
                      Occupation and Employer:
                      Why on Premises:
                      Nature and Extent of Injury:

                      Owner and Address:
                                                                             Telephone No.:
   PROPERTY
     DAMAGE           Description of Property:
 IF APPLICABLE
                      Describe Damage:
                      When/Where can Property be Inspected:
                      NAME                                        ADDRESS                                      TELEPHONE NO.
   WITNESSES


                      Identify Police Authority Investigating:
POLICE REPORT
                      Date of Report:                                          Report No.:
                      List doctors, hospital or facilities giving treatment (include complete name & address):


   TREATMENT
       AND
     BILLING
                      Amount of total doctor(s) bill(s):                                 Hospital bill(s):
                      (Itemized bills must be attached)                                  (Itemized bills attached)
                      Are you receiving medical treatment at present?               Yes        No
                                                                                                                          225-085-03
                                                                                                                   GENERAL COUNSEL
                                                                                                                               06/11
                                                                                                                          Page 2 of 2



                      Were you in the course of your employment?                  Yes         No
                      Did you lose income?         Yes       No    (If yes, list employers of past 3 years)
                           NAME                          ADDRESS                                         PHONE
                      1.
                      2.
                      3.
                      (Lost wages must include a signed statement from employer itemizing date and pay lost.)
                      Date disability began:                                 Date returned to work:
  EMPLOYMENT
                      List any other expenses (nurses, drugs) and please enclose supporting bills.




                      Do you have any existing claim for worker’s compensation, personal injury protection, or claim
                      of personal injury?   Yes      No
                      (If yes, list date, place, type of accident, and injury):


                                                                                                        (Use back if needed)
                      List any accident in which you received any type of injury in the past 5 years. If none, indicate
                      “none”:
PREVIOUS CLAIMS
                                                                                                        (Use back if needed)
                      Identify police authority investigating:


ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE
COMPANY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING
INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.



           DATE OF REPORT                                                          SIGNATURE OF PERSON FILING REPORT



Sworn to and subscribed before me this                 day of                          ,            (name of affiant). He/She is
personally known to me or has produced                                            (type of identification) as identification.

State of



                                                                    (Notary’s printed name)              My commission expires

				
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