XX 11am. Police report for Paul Insured case received.

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Gerald Francis
6 years ago
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1 INSURCO File Notes: Julian Claimant XX 4pm. Call from Paul Insured. Paul Insured reported that he d been involved in a MVA that was his fault. He hit another vehicle as he was pulling out of a parking lot onto Frontage Road. He says he was cited and will get us the police report. He reports minimal damage to his vehicle, no injuries to anyone, minimal damage to other vehicle driven by Julian Claimant. Advised Paul Insured that an appraiser will contact him to inspect the vehicle XX 11am. Police report for Paul Insured case received XX 10am. Rec d call and fa from John Attorney reporting that he represents the claimant in the Paul Insured Case, Julian Claimant. Caller s phone XX 2pm. Call from claimant Julian Claimant. Rec'd a call from Julian Claimant who said several people have tried calling him, attorneys etc. He wants to know who he should be talking to. I let him know that John Attorney reported he is representing him so I can no longer discuss this w/ him. He wanted to know if he should be going to the Dr appt. Told him he needs to talk to his atty. We do not have any say in that. He said he was fine now. Told him he needs to go thru the atty office if he signed agreement w/them. I did let him know that our appraiser would be contacting him to make arrangements to inspect his vehicle XX 10am. Call from Julian Claimant. Obtained recorded statement from Julian Claimant with atty present on phone. Claim Rep: Was anyone injured in the loss? Claimant: Yes, I was (Julian Claimant). Claim Rep: What body part is injured? Claimant: Rt arm and shoulder area. Claim Rep: Are you planning to seek additional treatment? Claimant: Yes, has appt for this afternoon. Claim Rep: What is the name of the facility(s) or doctor(s)? Claimant: Does not know name of Dr or facility XX. Appraiser photos of both vehicles received XX 8am. Received bill and progress notes from E. Harrington Physician for services rendered to Julian Claimant in July XX. Received bill for July services to Julian Claimant, from Rock City Rehabilitation.

Revised Report CRASH Police Crash Report Crash MM DD YYYY Day of Week MILITARY Time (24 hr clock) County of Crash Official DMV Use Date GPS Lat. GPS Long.

2 Revised Report CRASH Police Crash Report Crash MM DD YYYY Day of Week MILITARY Time (24 hr clock) County of Crash Official DMV Use Date GPS Lat. GPS Long. Page of City of City or Town Name Landmarks at Scene Town of Location of Crash (route/street) Railroad Crossing ID no. (if within 150 ft.) Local Cas N S E W Location of Crash (route/street) Mile Marker Number Number of Vehicles At Intersection With or Miles Feet of DRIVER VEHICLE # Driver Fled Scene Driver s Name (Last, First, Middle) Gender VEHICLE # DRIVER Driver s Name (Last, First, Middle) Driver Fled Scene Gender M F M F Address (Street and Number) Address (Street and Number) City State ZIP City State ZIP Birth Drivers License Number State DL CDL Date MM DD YYYY Safety. Used Air Bag Ejected Date of Death Injury Type EMS Transport Summons Issued As Result of Crash VEHICLE Vehicle Owner s Name (Last, First, Middle) MM DD YYYY Offenses Charged to Driver Y Same as Driver N Birth Drivers License Number State DL CDL Date MM DD YYYY Safety. Used Air Bag Ejected Date of Death Injury Type EMS Transport Injured Summons Issued As Result of Crash VEHICLE Vehicle Owner s Name (Last, First, Middle) MM DD YYYY Offenses Charged to Driver Y Same as Driver N Address (Street and Number) Address (Street and Number) City State ZIP City State ZIP Vehicle Year Vehicle Make Vehicle Model Disabled CMV Towed Vehicle Year Vehicle Make Vehicle Model Disabled CMV Towed Vehicle Plate Number State Approimate Repair Cost Vehicle Plate Number State Approimate Repair Cost VIN Name of Insurance Company (not agent) PASSENGER (only if injured or killed) Codes POSITION IN/ON VEHICLE 1. Driver 2-6. Passengers 7. Cargo Area 8. Riding/Hanging On Outside All Other Passengers SAFETY EQUIPMENT USED 1. Lap Belt Only 2. Shoulder Belt Only 3. Lap and Shoulder Belt 4. Child Restraint 5. Helmet 6. Other 7. Booster Seat 8. No Restraint Used 9. Not Applicable Oversize Cargo Spill Override Underride Speed Before Crash Speed Limit Maimum Safe Speed ALL Passengers Age Count Under Over VIN Name of Insurance Company (not agent) Injured Injured Injured Oversize Cargo Spill Override Underride Speed Before Crash Speed Limit Maimum Safe Speed ALL Passengers Age Count Under Over PASSENGER (only if injured or killed) Name of Injured (Last, First, Middle) Name of Injured (Last, First, Middle) EMS Transport Date of Death EMS Transport Date of Death MM DD YY MM DD YY Position Safety Airbag Ejected Injury Type Birthdate Gender Position Safety Airbag Ejected Injury Type Birthdate Gender In/On M F In/On M F Vehicle Used MM DD YYYY Vehicle Used MM DD YYYY Name of Injured (Last, First, Middle) EMS Transport Date of Death Name of Injured (Last, First, Middle) EMS Transport Date of Death MM DD YY MM DD YY Position Safety Airbag Ejected Injury Type Birthdate Gender Position Safety Airbag Ejected Injury Type Birthdate Gender In/On M F In/On M F Vehicle Used MM DD YYYY Vehicle Used MM DD YYYY Name of Injured (Last, First, Middle) EMS Transport Date of Death Name of Injured (Last, First, Middle) EMS Transport Date of Death MM DD YY MM DD YY Position Safety Airbag Ejected Injury Type Birthdate Gender Position Safety Airbag Ejected Injury Type Birthdate Gender In/On M F In/On M F Vehicle Used MM DD YYYY Vehicle Used MM DD YYYY AIRBAG 1. Deployed Front 2. Not Deployed 3. Unavailable/Not Applicable 4. Keyed Off 5. Unknown 6. Deployed Side 7. Deployed Other (Knee, Air Belt, etc.) 8. Deployed Combination EJECTED FROM VEHICLE 1. Not Ejected 2. Partially Ejected 3. Totally Ejected SUMMONS ISSUED AS A RESULT OF CRASH 1. Yes 2. No 3. Pending INJUR Y TYPE 1. Dead Before Report Made 2. Visible Signs of Injury, as Bleeding Wound or Distorted Member or Had to be Carried From Scene. 3. Other Visible Injury, as Bruises, Abrasions, Swelling, Limping, etc. 4. No Visible Injury, But Complaint of Pain, or Momentary Unconsciousness. 6. No Injury (driver only) Investigating Officer Badge/Code Number Agency/Department Name and Code Reviewing Officer Report File Date

3 DOCUMENT XX hrs 1

4 DOCUMENT 3 Claimant, Julian Carol St 17 XX RECEIVED BY INSURCO Rock City XX S43 409A R Shoulder S/S S13 4XXA S23 8XXA Cervical S/S Thoracic S/S XX XX c1234 E. Harrington Physician 8/2/XX 41 Medical Plaza Rock City Medical Plaza Rock City

DOCUMENT 9 Claimant, Julian 08 315 Carol St 17 XX Rock City RECEIVED by INSURCO 50700 07 02 XX S43 409A R Shoulder S/S S23 8XXA S13 4XXA Cervical S/S Thoracic S/S 08 13 XX 11 99215 202 00 1 08

5 DOCUMENT 9 Claimant, Julian Carol St 17 XX Rock City RECEIVED by INSURCO XX S43 409A R Shoulder S/S S23 8XXA S13 4XXA Cervical S/S Thoracic S/S XX XX XX XX c1234 E Harrington Physician 41 Medical Plaza 9/2/XX Rock City Medical Plaza Rock City

6 DOCUMENT 13 Rock City Medical Imaging 61 Medical Plaza Rock City, Date: 9-11-XX To: Plaza Des Moines, Patient: Julian Claimant Referring Physician: E. Harrington Physician, MD Date CPT Procedure Case Total 9-11-XX Magnetic resonance (eg, proton) BR imaging, spinal canal and contents, cervical; without contrast material; technical component and interpretation Balance Due: $ Please remit at your earliest convenience. Thank you for your business.

DOCUMENT 16 Claimant, Julian 08 315 Carol St 17 XX RECEIVED by INSURCO Rock City 50700 07 02 XX S43 409A R Shoulder S/S S23 8XXA 09 25 XX S13 4XXA

7 DOCUMENT 16 Claimant, Julian Carol St 17 XX RECEIVED by INSURCO Rock City XX S43 409A R Shoulder S/S S23 8XXA XX S13 4XXA Cervical S/S Thoracic S/S c1234 E Harrington Physician 41 Medical Plaza 10/2/XX Rock City Medical Plaza Rock City

8 DOCUMENT 19 Weldon Paindoctor, MD, PA 75 Medical Plaza Rock City, Date: 11-3-XX Invoice #2201 To: Plaza Des Moines, For: Consultation with Julian Claimant Qty DOS CPT ICD.10 Procedure Price Total XX M54.16 Initial Consultation We appreciate your business! Feel free to contact me if you have any questions.

9 DOCUMENT 21 Gavin Neurosurgeon, MD, PA 99 Medical Plaza Rock City, Date: 11-9-XX Amount Due $ Amount Paid Invoice # To: Plaza Des Moines, For: Eamination of Julian Claimant DOS Description XX Cervicalgia, M54.2 Displacement of cervical intervertebral disk without myelopathy, M50.20 Brachial neuritics or radiculitis NOS, M54.12 We appreciate your business! Feel free to contact me if you have any questions.

10 DOCUMENT 22 Gavin Neurosurgeon, MD 99 Medical Plaza Rock City, Gavin Neurosurgeon, MD Board Certified Neurosurgeon

XX 11am. Police report for Paul Insured case received.

XX 11am. Police report for Paul Insured case received. INSURCO File Notes: Julian Claimant 1. 7-2-XX 4pm. Call from Paul Insured. Paul Insured reported that he d been involved in a MVA that was his fault. He hit another vehicle as he was pulling out of a parking