Motor Vehicle Accident Settlement Form

Patient First Name
Patient Last Name
Hospital Account #
Total amount due

PIP Status
Is the PIP exhausted?
$2,000 yes no
$8,000 yes no
Have any of the PIP moneys been paid to the hospital? yes no

Med Pay Status
Were there any med pay moneys available? yes no
If yes, maximum med pay amount
If yes, have the med pays benefits been exhausted yes no

Other Status
Is there any underinsurance or unisured motorist coverage? yes no
Is there any other source of funds? yes no
If yes, please explain.

Is there any health insurance available? yes no
If yes, provide company name and id number.

Total amount of oustanding medical bills
Amount of additional liens against the settlement
What is the total settlement amount?
What is the amount you are proposing?
Are there any additional factors to be considered with your proposal? Please explain.