Form 1270F© 2004 Nationwide Publishing Company, Inc.http://www.claimspages.com.APPLICATION FOR BENEFITS—AUTO PERSONAL INJURY PROTECTIONInsurance Company ToClaims DeptTO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE AUTOMOBILE PERSONALINJURY PROTECTION LAW, PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY.ACCIDENT INFORMATIONName: Address:Phone Number: City, State, Zip:Date of Accident: Location of Accident:Description of Accident:.MEDICAL INFORMATIONWere you injured as a result of the accident? If yes, complete the rest... Download File
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Form 1220F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com WAGE AND SALARY VERIFICATION DATE OUR POLICY HOLDER DATE OF ACCIDENT FILE NUMBER EMPLOYEE NAME: EMPLOYER NAME: ADDRESS: ADDRESS: CITY, STATE: CITY, STATE: ZIP CODE: ZIP CODE: SS#: SUPERVISOR: Dear Employer: The person named above has applied...
Form 1200F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com WITNESS ACCIDENT REPORT (AUTOMOBILE) Date of Report: Time M. Location of Accident Date of Accident , 20 Time M. Did you see the accident? If not, how soon after did you see it? Where were you located? CARS INVOLVED IN ACCIDENT No. 1 Make Direction on...
Form 1190F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com DRIVERíS STATEMENT Driverís Name: Ownerís Name: Driverís Address: City: State: Age: Phone Nbr: Driverís License Nbr: State: EXP: // Employed By: Address of Employer: What was the vehicle being used for at time of accident? Date of Accident:...
Similar to Automobile Accident Report (1160F), this form is given to claimants to capture the details of an accident. Includes damages, occupants and witnesses.
Report form that is given to vehicle owners and drivers to capture the details of an accident. Includes occupants, injuries, damages and witnesses.
A sworn statement by a policyholder on an automobile claim. Filled out and notarized, this is a formal request by the insured for payment from the insurance company.
A loss report form filled out by insureds and/or agents when reporting an automobile accident. Includes information on occupants, injuries, damages and witnesses.
Automobile Loss Notice (Acord)
Digital Photo Sheet 2
INQUIRY FORM BASED UPON REPORT OF INDEX SYSTEM Date: Your File No: Insured: Claimant: Address: Date of Loss: Your index card on the above case was shown on an Index System Report. To assist us in the handling of our clam, we will appreciate your cooperation in furnishing the additional information listed below. Please have this...
Form 1100F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com PASSENGERíS STATEMENT Name: Address: Occupation: Employed by: Age: Driving Experience: Date of accident: Hour Day or night? Location of accident: Vehicle Year, Make, and Model (that you were in): Was the vehicle in good operating order at...
Form 3250F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com . Dr. Please furnish the following report regarding my condition. Signed MEDICAL REPORT Name Age Address Occupation Employed by Date of Accident , 20 History as described by patient Date of your first treatment ,20 Date taken , 20 Where taken Findings In...
Form 1070F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com NOTICE OF SUBROGATION RIGHTS Claim Number: On , you or your vehicle was involved in an accident with, our policyholder. We have settled with our policyholder and now look to you for reimbursement of $. If you were covered by insurance, merely complete...
Form 1060F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com RELEASE AND TRUST AGREEMENT Uninsured / Underinsured Motorist Coverage PROPERTY DAMAGE ONLY I/we, for the sole consideration of dollars ($) to be paid by , hereinafter called the Company, the undersigned in his/her/their capacity as insured(s), and/or...
Create your own time line using this Microsoft Excel template. Just enter dates and labels.
A release form signed by an insured when making an uninsured motorist or underinsured motorist claim. Requires the insured to cooperate in the recovery of funds from the responsible party.
A declaration by an insured person that he/she was not being transported for a fee at the time of the accident, and otherwise qualifies for medical expense coverage under the policy.
Used as a general release form which is signed by insureds and specifies the payments that are authorized to be issued.
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