Sample Demand Packet Index


{Adjuster’s Name and Title}
{Name of Liability Insurance Carrier}
{Address – Line 1}
{Address – Line 2}
{City, State and Zip Code}

Claim No:                  {}
Claimant:                   {}
Your Insured:           {}
D/Loss:                       XX/XX/XXXX


Exhibit A – Arizona Crash Report

Exhibit B – Photographs of Client’s/Claimant’s Injuries, Scene, and Vehicles

Exhibit C – Vehicle Repair Estimates (Showing Vehicle Damage & Location)

Exhibit D – Medical Records & Itemized Billing Statements

  1. {Ambulance (include records and billing statement)} $
  2. {Hospital (include records and billing statement)}
  3. {Emergency Room (include billing statement only)}
  4. {Physician Specialist (include records and billing statement)}
  5. {In Patient Hospitalist (include records and billing statement)}
  6. {Rehabilitation Facility (include records and billing statement)}}
  7. {Physical Therapy (include records and billing statement)}}
  8. {Chiropractor (include records and billing statement)}
  9. {Other medical providers (include records and billing statement)}
  10. {Prescriptions (include records and receipts)} $      

Total Medical Specials:                                                                                ${} 

Exhibit E – Lost Wages/Income:

  1. Lost Wages {include employer off-work statement or pay stubs}: $

Total Lost Wages/Income:                                                                           ${}

Exhibit F – {Any other claims such as future care and supporting documents}

Total Special Damages Claimed:                                                                $