{Today’s Date}
DEMAND LETTER FOR
SETTLEMENT PURPOSES ONLY
Sent via facsimile: {(xxx) xxx-xxxx}
{Adjuster’s Name and Title}
{Insurance Company Name}
{Address – Line 1}
{Address – Line 2}
{City, State, Zip}
Re: Our Client: {Claimant’s Name}
Claim No: {}
Your Insured: {Insured’s Name}
Date of Loss: {}
Dear {Adjuster’s Name}:
{Client/claimant’s} has completed {his/her} medical treatment and submits this demand letter and packet as a good faith effort to resolve this matter.
Factual Background
Our client, a restrained driver, operating a {year, make and model of vehicle}, was traveling westbound on {name of street} in {name of city}, Maricopa County, Arizona, when your insured, operating a {1-ton/2-ton} box truck, traveling southbound on {name of street}, ran a red light at the {} intersection and violently slammed into the passenger side of {client/claimant’s} vehicle. It was estimated that your insured was traveling {} mph at the time of impact. The impact was so intense that it caused {client/claimant’s} vehicle to spin 360 degrees (observed by eyewitnesses) and ultimately collide into a third vehicle, a {year/make/model}, operated by {name of third-party}. Your insured was cited at the scene for violation of A.R.S. § 28-645A3A (failure to stop at a traffic controlled red light). An eyewitness recorded the infraction on his dash-cam.
The impact was violent. {Client/claimant’s} vehicle sustained crushed metal/damaged frame, was towed from the scene. It was deemed a total loss as a result of this accident.
Injuries & Damages
{Include pertinent entries in timeline format including hospital charting, specialist charting, nurse’s notes, physical therapy notes, rehabilitation notes, X-ray/CT Scan/MRI diagnostic findings, chiropractic charting, pain levels, and/or any other healthcare provider charting or notes that documents the nature and extent of treatment as well as pain levels. Also, include specific preliminary and final diagnoses charted by medical professionals. Include ICD and CPT codes that correlate with the diagnoses, which can be found in the medical charting and/or itemized billing statements. Many insurance companies use computer generated evaluation software that will interpret and consider ICD and CPT codes as part of their evaluation process.}
Preexisting Conditions
{This section is optional if client/claimant had a similar past injury. Include records from the last three to five years prior to the accident that is the subject of this demand letter. Include any references to the client/claimant reaching maximum medical improvement and the date {he/she} was last seen or treated prior to this new accident.}
Medical Specials
{Client/claimant’s name} has incurred the following out-of-pocket medical expenses due to this accident:
{Ambulance} $
{Hospital}
{Emergency Room Physicians}
{Anesthesiologist}
{Orthopedic Consultant}
{Diagnostic Testing / X-rays, CT Scan, MRI}
{Follow-up Specialists}
{Rehabilitation Center}
{Physical Therapy}
{Chiropractor}
{Other Accident Related Medical providers}
{Prescription Drugs} $
Total Medical Specials: $
Future Medical Treatment
{Discuss any future medical treatment and/or surgery that the client will need as a result of this accident. This will require medical expert opinion as to type and cost of future care should the case go to trial.}
{The cost of client/claimant’s future care including surgery and post-surgical care is to be determined.}
Total Future Medical Specials: To be determined
Wage Loss
{Calculate wage loss based on wage loss verification received from client/claimant’s employer. If self-employed, include tax return information showing decrease in earnings and lost opportunities as a result of accident.}
{Client/claimant} missed ____ hours of work as a result of this accident, which included ____ hours of regular time and ____ hours of overtime. He {insert profession and job duties} and earns $____/hour for regular time and $____/hour for overtime. Prior to this accident, {he/she} typically worked a ____-hour per week with consistent overtime. {Client/claimant’s} total wage loss is documented as follows:
____ hours – regular pay $___.00/hour = $
____ hours – overtime pay (time-and-a-half) $___.00/hour = $
Total Lost Wages: $
Future Impairment to Labor & Earn Income
{Discuss any inability to resume current line of work and the impact it will have on future ability to earn income. This will typically require an impairment rating by a medical specialist and a vocational expert opinion in order to claim any amount should the case go to trial.}
Total Future Impairment Earn Income: To be determined
General Damages
{Client/claimant} is entitled to compensation for {his/her} pain and suffering as a result of this accident. The impact was unexpected and violent. Based on the negligent actions of your insured,
{Client/claimant} has excellent testimonial qualities. {Document any commitment to his/her family, work, community. List any hobbies that were affected as a result of this accident including type of activity level and duration he/she was prevented from participating in such hobbies. Also, discuss that he/she did not overtreat and did everything possible to get to how he/she was before the accident. If permanent injuries are involved, discuss those permanencies and how it will impact him/her for the rest of his/her life.}
Demand for Settlement
Given the clear liability, nature and extent of injuries and hard dollar special damages, {client/claimant} is willing to settle {his/her} claim for $____________ in exchange for a full release of your insured. {If you have good indication that the policy limits are exposed, you could ask for the policy limits and request of copy of the insurer’s declaration of coverages page to provide to any underinsured carrier(s) for the difference between the demand and amount paid by the liability insurance carrier.}
We look forward to your response.
Sincerely,
{YOUR LAW FIRM NAME}
{attorney’s name}
Enclosure