Who is receiving this demand letter? Who is receiving this demand letter? The driver at fault The driver's insurance company Do you want to include your case number? Do you want to include your case number? YesNo Insurance case number Did you sustain any injuries from the accident? Did you sustain any injuries from the accident? YesNo Do you want to list these injuries now? Do you want to list these injuries now? YesNo, I will enter it later. Describe your injuries from the accident: Did you receive any medical care for these injuries? Did you receive any medical care for these injuries? YesNo Do you want to list the medical details now? Do you want to list the medical details now? YesNo, I will enter it later. i.e. Where you received the medical care, the types of exams and treatment you received, and estimated cost Name of hospital / medical care center Medical tests / treatments received: Estimated total cost of medical care $ Will you be receiving follow-up care (e.g. physical therapy) for your injuries? Will you be receiving follow-up care (e.g. physical therapy) for your injuries? YesNo Did you lose any wages or earnings due to the accident? Did you lose any wages or earnings due to the accident? YesNo Do you want to detail the lost wages and earnings now? Do you want to detail the lost wages and earnings now? YesNo, I will enter it later. Total lost wages / earnings $ Provide details for lost wages and earnings: Did you incur any out-of-pocket expenses for vehicle repair? Did you incur any out-of-pocket expenses for vehicle repair? YesNo Do you want to list the vehicle repair costs now? Do you want to list the vehicle repair costs now? YesNo, I will enter it later. Estimated vehicle repair expenses $ List the out-of-pocket expenses for vehicle repairs: Did you suffer emotional hardship or suffering due to the accident? Did you suffer emotional hardship or suffering due to the accident? YesNo Do you want to explain your emotional suffering now? Do you want to explain your emotional suffering now? YesNo, I will enter it later. Explain the emotional hardship you've been suffering: Payment for pain and suffering $ There is no amount that can be justified for pain and suffering. Therefore, it's best to lookup cases with similar injuries to get an idea of how much someone's "pain and suffering" is worth in the court of law. Do you want to outline the details of the accident now? Do you want to outline the details of the accident now? YesNo, I will do this later. i.e. Date, time, location, and summary of accident Date of accident Approximate time of accident What is the vehicle you were driving? i.e. Make and model Where did the accident occur? Describe what happened: What is the total amount you are demanding? $ This includes all expenses for medical care, vehicle repair, lost wages, and emotional hardship. Name of the other driver , Enter your name Do you want to add your mailing address? Do you want to add your mailing address? YesNo, I will enter it later. Street Address City, State Zip Code Letter date Do you want to electronically sign this letter? Do you want to electronically sign this letter? YesNo Sign your name below Clear Please draw your signature. Next Save Save and finish later
