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14. Please provide the following information and materials: <br />a. Verified copies of all bills or expenses claimed to have been incurred <br />as a result of the incident or accident. <br />b. Medical reports detailing the diagnosis, prognosis and causation of <br />any claimed injury, together with a statement as to the nature and <br />extent of permanent injury, if any. <br />Certified appraisals or repair estimates of property damage, if any. <br />d. Verified statement of loss of wages and /or time and /or sick leave used <br />from employer. <br />e. Amount and nature of Workers' Compensation payments, if any. <br />f. Nature and amount of payments received under medical plans, and <br />the name of said medical plan, if any. <br />g. Other: <br />SIGNATURE OF CLAIMANT <br />DATE OF CLAIM <br />*PLEASE BE ADVISED THAT FILING OF YOUR CLAIM WITH THIS OFFICE DOES NOT FULFILL YOUR NEED TO <br />FILE A LAWSUIT IF YOU DISAGREE WITH THE DECISION ON YOUR CLAIM, REGARDLESS OF WHETHER YOUR <br />CLAIM IS TIMELY INVESTIGATED AND A REPLY MADE TO YOU WITHIN THE APPLICABLE PERIOD OF <br />LIMITATIONS WHICH MAY BE AS SHORT AS TWO YEARS. <br />7/10 <br />n <br />