West Palm Beach Florida car accident Damages Record Call 1-800-74-TRIAL

Name of Client: _______________________________________________
File #: _______________________________________________________

1. Wage Loss Information
a. Time lost from work _____________________________
b. Wages lost ______________________________________
c. Other wage loss data ____________________________
Subtotal $ ______________________________________

2. Property Damage (Expenses associated with West Palm Beach Florida car accident)
a. Automobile repair _______________________________
b. Towing __________________________________________
c. Car rental ______________________________________
d. Car storage _____________________________________
e. Other property damage ___________________________
f. Miscellaneous: glasses, wristwatch,
jewelry, clothing, etc. _________________________
Subtotal $ ______________________________________

3. Transportation (Expenses associated with West Palm Beach Florida car accident)
a. Cab _____________________________________________
b. Buses/trains ____________________________________
c. Airplanes _______________________________________
d. Rentals _________________________________________
e. Mileage _________________________________________
Subtotal $ ______________________________________

4. Medical (Expenses associated with West Palm Beach Florida car accident)
a. Physicians (date, amount, reason) ___________________________________
b. Laboratory (date, amount, reason) ___________________________________
c. Hospital (date, amount, reason) _____________________________________
d. Ambulance (date, amount, reason) ____________________________________
e. Medication (date, amount, reason) ___________________________________
f. Physical therapy (date, amount, reason) _____________________________
g. Nurse (date, amount, reason) ________________________________________
h. Home health care ((Expenses associated with West Palm Beach Florida car accident) associated with West Palm Beach Florida car accident)(date, amount, reason) ____________________
i. Miscellaneous ((Expenses associated with West Palm Beach Florida car accident) associated with West Palm Beach Florida car accident)(date, amount, reason) _______________________
Subtotal $__________________________________________

5. Housekeeping/Home Aid (Expenses associated with West Palm Beach Florida car accident)
a. Name of housekeeper/helper _________________________
b. Number of weeks used _______________________________
c. Wages per week _____________________________________
d. Miscellaneous home aid ((Expenses associated with West Palm Beach Florida car accident) associated with West Palm Beach Florida car accident)____________________
Subtotal $ _________________________________________

6. Special Purchases
a. Wheelchair _________________________________________
b. Neck brace _________________________________________
c. Back brace _________________________________________
d. Corsets ____________________________________________
e. Traction devices ___________________________________
f. Special clothing ___________________________________
g. Heating pads _______________________________________
h. Ice packs __________________________________________
Subtotal $ _________________________________________

Total $ ____________________________________________