Date and Type of Injury: Claim No. 6. Injury Location: Claim No. 2.
You can forward your claim by postal mail or fax to: 6201 West 9th Place, Suite 830, Cleveland, OH 44109. Include the following materials. 1. Statement of the nature and cause of the claim: Statement of the nature and cause of any injury, illness, or condition Claim No. 6 and any other information requested by the claims' administrator. 2. The date and time of the accident: Date and time of the accident of Claim No. 6 and any other information requested by the claims' administrator. 3. The date and time of the alleged injury and the name of a representative who witnessed the injury. The name and address of any witnesses who witnessed the event are hereby requested. 4. Instructions for your claim: Instructions for completing one or more of the claims form. 5. An itemized estimate of the amount of damage caused by the accident. 6. A copy of any medical bills, if any. 7. Payment for the damage to your vehicle. 8. Your name and telephone number. If you would like to discuss this matter further, please call:. To discuss your benefits status, please call:.
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Worker s Compensation You received a letter regarding a pending claims' investigation. Our investigation of this claim indicates that it may be related to an occupational injury or illness. Please
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