INFORMATION SHEET  (DO NOT SEND TO INDEX BUREAU)



                                                                                                                                               HUSBAND OR WIFE, FORMER NAME’S
CLAIMANT’S NAME                              FIRST               MIDDLE                          LAST                                                           PARENTS OF MANORS, OR ALIASES
 


RESIDENCE (ADDRESS IN FULL)
 


FORMER RESIDENCE
 


BIRTHPLACE                                                                            DAY OF BIRTH (OR AGE)                      SEX                       RACE                          MARITAL STATUS
 


HEIGHT                              WEIGHT                      HAIR              EYES                                                                               OCCUPATION
 


SCARS OR DEFORMITIES                                                                                                                                                   SOCIAL SECURITY NUMBER
 


DATE OF ACCIDENT                                                                                                                                                          PLACE OF ACCIDENT
 


INJURIES
 


DOCTOR (CLAIMANT’S)                              LAST NAME                              FIRST                          MIDDLE                    FULL ADDRESS
 


ATTORNEY (CLAIMANT’S)                         LAST NAME                              FIRST                          MIDDLE                    FULL ADDRESS
 


INSURED
 


REPORTING OFFICE CODE NO.                                                       TYPE OF CLAIM                                                         CASE FILE NO.
 


REMARKS
 


 
 


 
 

                                                                                                                      ADJUSTER ______________________________________________________________________
 

                                                                                                                     ADJUSTING FIRM ________________________________________________________________