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Sample Demand For Settlement
For Motor Vehicle Accident Claim


DEMAND  FOR SETTLEMENT

Summary Itemization of Elements of Recovery

               Name of Claimant
   
               Your insured:     
              
Date of Injury:
               Name of Insured
               Insurance Carrier Claim Number:

 

I. Biographical Information

        1. Date of Birth

         2. Age: 

        Photo Graph Attached

        2. Education
                a. High School:
                b. College

      3. Occupation:

       4. Interest and hobbies

II.   Liability


    A. Liability of Insured/Defendant: ___________________   

    Liability is conclusive against your insured ____________ 
    for the following reasons.

        (1) Accident Report: 

            (a).  See Copy of accident Report Attached-Exhibit A.

        (2)Violations of Statute By Your Insured:

                (a) Violation of California Motor Vehicle Code Sections: (Examples)
                       Violation of California Motor Vehicle Code Sections 22107 (Unsafe Turning Movement
                       Violation of California Motor Vehicle Code Sections  22350 (Speeding For Conditions) 

           (2) Legal references - Book of Approved Jury Instructions -(BAJI)
                 BAJI NO: 

                    
III.  NATURE AND EXTENT OF IMPACT

       A. Physical Damage

        See Police Report
       See Photo Graphs - Your  Insured Car: ______ Photographs
       See Photo Graphs -Claimant's car: ______ Photographs
       See Photo Graphs - Damage To Other Property: ______ Photographs
        Repair Estimates
        Repair Invoices/billing

        A.  Injuries to claimant:

            See Photo Graphs of Claimant's Injuries: ______ Photographs

iv. DAMAGES

    Medical Expenses


    1.    Doctor John Doe------                                                                        $ 00000000
           Dr. John Doe Medical report Attached

    2.    Doctor Mary Doe------                                                                        $ 00000000
           Dr. John Doe Medical report Attached

                      Total Medical Expenses

V. Other Special Damages

        Loss of use

            Loss of use of damaged vehicle - General Inconvenience
            (Receipts And or Invoice Attached)
            Loss of Use Rental Commercial
            Loss of use Expense -  Public transportation
            Loss of use Expense -  Payment to Relative or
Friend

       Loss Of Income  To Dare

       Period - Time off From Work: 
       See Letter from Employer
       Self-Employed -- 
                        (1) List of Jobs Lost
                        (2) Extra Help
                        (3) 

     Future Loss of Income


     Permanent  Loss And Impairment Of Earnings Capacity

            Total Loss of Income

   Total Other special damages

V.  General  Damages - Pain And suffering


    A. Amount demanded for pain and suffering

        (1) General Pain And suffering
               (see Exhibit ____ List of Limited activity

        (2) Anticipated Future Discomfort-
             See medical Report of Dr _________; Exhibit ___ Attached
       
        (3) Risidual Injuries:

        (4) Permanrnt Disability


   Total General damages demanded

Total special and general damagesgeneral,

 

V.   Punitivel  Damages - Exemplary California civl code

       Conduct warranting punitive damages

       

Date Demand Submitted                                                                                         

 

end of document



Attachment to demand

Unable to do list - Exhibit ____

 

-    I could not return back to the Bay Area as planned

 

-    I was unable to drive home resulting in additional expense,

    i.e., rental car/airplane ticket

 

-    I am unable to lift anything more than five (5) or ten (10) lbs.

-    Right/feft Hand goes numb when I am on the telephone for long periods of time

-    Unable to coach vollyball classes or participate in any manner

-    Limited computer work

-    Unable to run, hike, bike, swim, lift weights, mountain climbing

-    Unable to drive home to Santa Barbara

-    Unable to walk for any length of time without tiring

-    Terrified of driving on the freeway

-    Unable to work

-    Unable to do yoga, stretching