APPLICAnON FOR PERSONAL INJURy PROTECTION BENEFITS !'3.

USAA CaIuIItJ ......... CompIUIJ

MemDerName I USAA~ IURN~I o.~LaIS PATHM' NAM. DATI OF 811lTM

MIIIII8& tJO.. ......,. CITV OR 10Wft ..,.ATI. MD ZIP CDDIJ I40Me PHONI! ISU ..... PMDNI I ) C I

DATI NIO TIM! OF ACCIDINT I PI.ACIl OF ACCIOItn' 1I1UIT. CITY OR TGWN. AND STA11!I

IRIIIP Dl8CRIPTION OF ACCIaHT AID AUTOMOBILI! YOU OCCUPIIO OR WI!RI II'RUCK 8'1

AT ,. OF ACCIDlN1': WEIll! YOU AN ot::c:'UPAN'I' OF OUR MEUllEa's CARl a yea CNO WAS YOUR IllATlaTICHILD III!$TRAINT IN .,., DVes DNO waf! YOU RIDING dI A SlAT PROTICTIO av AN AI.Am a va C NO DOes YOUR MOUGIHOLD MAVE AJN 01Na AitrO

WIllI! 'IOU A PI!DI!I1RIAN STIIUCIt BV OUR ...... 81'8 CNtI a yea C NO INSIIRANCI POLICIU? aves aNO

WIllI! YOU IN 'lMe COURI8 0' YOUR EIIIPLDYIIII!III? aves CNO

HAve YOU RlCeIVlD OR AlII! YOU ILIG .... FOR .. otCAl OR DI8A8IL1TV 8PlEF1TS UNDER

l" ANY WOUIAS' COMPINSATtON PI.AfQ aVIS CNO AMf OF 8INI!PlT • tal ANY 0TI4IR IIINIPIT OR .fISURANCI PI.AfQ a VIS C NO IHAMfJ , to GOVIIINIIIN1' MlGlCAl I"ai~ DYU DNG INAMII ,

AS A ReSULT OF THIS ACCIII!N1' WI!RII YOU IILIUIIID1 c.,ea aNa ., YOUR ANIWIA IS -VIS'". COIIIIPUlTI! '1M! RUT OF 'lMIS'OAM. ., "NO"'. If. HBI AWD II!1UIIN nils FORM TO us. SI ... "'fURQ DATI!:

IlESCIII8fI YOUR INJURY

__ 'IOU TRIA,., 8Y A DOCTOIIt DAft OF 1ST 'nIIAfMllNl' DOCTOR'S NAMI AND A_ DVIS a-

li' YOU WIRI! 1'RIA1IO • A HOSPITM. WIfIfl 'YOU AN HOaPITAL'I NAMa ANO AIlDIIE88 D._ATlar COU1PA1'1BIT

:=.. ~=I:'':~~U:.J.:n.~ ~= ~:'ON~=ON RlVlIIIS S ... CVlS CND

HAve YOU IVIIII .. ""'QD FOR THIS 1'VPe OF IIU.IIlY OR COMOITION PRIOR TO TlttS ACClDI!tm IF 'III. PLI!A8I! PIOYIDI! 01\,.. AND OOCTORS ANDIOR MOSPtTALS WtIR TREATMENT WAS OBTAURiD ON RlVERIII SIll!.

DVIS DNG

HAG YOU IECOVIIIID flOM 1'HI8COND1T1ON AT 1Hl! TIM. OF 1Hl! ACCIDItm DViS CNG

AM1iUN'f OF M.ICAL IIWI TO DATI • WILL YOU HAVI MORe MlDlCAL 8l1.l.I' DViS gNG AS A II!IULT OJ 'lOUR IIII.IVRY. WILL YOU HAVI! ANY O'IMER IXPI!NIt!I. IJlCWOING TRANSPORTATION IXPI!N.SP II • IUASI! IXPlAIN ON MVIR8E.

CVII CNG

DID YOU LOll TIM! PROM VOUR IMPLOYMINT AS A AIlIULT OF YOUR ,uurn DVes aNO WHAT IS VOUR AVERAGII WHICLY WACII I' VIS. AMOUNl' OP TIMe LOST TO DATI OR SALARVP

" YOU LOST TlMf. DIVI DATI DISABILITY PROM WONt IlI!GAIf DATI RllTURHID 1'0 WORlt

LIlT NAMe AND ADaRISI 0' 'lOUR IMPLOVI!R AT 1M! DATI! O' 1M! ACCtDINr. alve OCCUPATION AND DATIS DP eMP&.OYMINT.

IMPLDVI!R AND ADDIII!8S OCCUPATION PROM TO ~-~---

_x". Dii' IMPORTAN1': 1. CCIMPLETe AND SIGN THIS APPLICATlON.

2. SIGN AND RETURN PROMPTLY AN'( A1TACHED AUTHORIZATlONCSJ. 3. SEND ANt MEDICAL BILLS YOU HAVE RECEIVED '1'0 DA'TE.

MAIIIt.pg .,."00808 MI - - 7fClli -8 -8837 170

I

AUTHORIZAnON FOR DISCLOSUJE OF MEDICAL INFORMATION TO UUA

I USAA Number 'Member IUIme IllR Number I Date at Lass

We .. not HIPAA coYa'8CI entities. yOW' cIscIoswe of Information to us is not subject to the MInimum Necessary standMi.

Patient:

I HEREBY GRANT PERMISSION TO, AND AUTHORIZE THE USE OR DISCLOSURE OF .. THE ABOVE NAMEDINDMDUAL'S RECORDS.

I authorize the following persons and organizations (a) any licensed pbysIc:Ian.. surgeon. or dentist; (b) any psychiatrist or psychologist; (e) any other medical practItIonw or nu .... : (eI) any hosp_ clinic, health care faclHty or rehabilitation/convalescent/custodial fadHty; (e) ambulance owner; (t) any insurance company (the -.rrovider'1 to provide information (as defined below) to UUA-CIC and/or their retrieval swvIce ABIIVIP.

I, the ......... gned, as the patient. or in my caoacIty as .,..,na • ...... entatlv. of the patient, .. understand the Information obtained by this AuthorIaItIon will be used by USAA-CIC and Its authorized representatives, paforming business or legal swvices, its affiliated Insurance companies, and Its authorized representatives, paformlng busln .. or legal services for the pwpose of verification, evaluation, and negotiation of any claim for benefits or ..-vices, .... ng fnHn the above-ldentlfied date of loss, and any ott. pertinent claim handling or legal uses In connection to such claims. or as USAA-CIC othawlse det .. mlnes Is necessary to underwrite Insurance.

For purposes of Ibis Author_tion, "Information" means all reconIs or knowIedae

concemlng the patient's health, any InJuries.. mecIcaI history, mental and physical conditions, before and after the date of this Authorization, regRless of the time of occurrence. The term ~ Includes, but is not limited to, written or waphic documentation, including notes,

MI • D· 7101·8 .18S7 170 51 ..... Pagat of3

billing records or statements, sound recordings, computer records of health care services, and diagnostic documentation, such as x-rays, lab test results, and other test results such as blood alcohol level and drug use. In addition to medical records developed by the Provider described above.. this Authorization also Includes any medical reCOlds received by the Provider from other providers.

This Authorization shall be In force and effect until all claims arising from the above-identified date of loss are .::conc::.;;:l:;::ud:=;ed::::r&.' ________ _

at which time this Authorization to disclose this Information expires.

I also understand and .wee to the following:

• Although this Authorization is volunta'y, .:.lJ=~;..;::.A..:..-CIC-=o:: _______ _ reserves the right to discontinue processing any claim If I refuse to grant this Authorization, and such refusal may be in breach of a policy condition if USAA-CIC reasonably needs this AuthorIzatIon to adequately Investigate any claim.

• That the information released lUSuant to this Authorization may be redIscIosed by USAA and may no longer be protected by federal privacy regulations.

• That I may receive a copy of this Authorization, and I have the right to revoke this Authorization, in writing,. at any time. I may request a copy or revoke the Authorization by sending such written request to

at

8800 Freda1cksbura Road, San Antonlo,TX 78288

• That a revocation is not effective: (I) until receipt by UU.A-CIC , and 01) to the extent that UU.A-CIC has relied on the use or disclosure of the Information.

• That: (1) this Authorization overrides any existing agreement to restrict Information pursuant to 4& CPR 164.&02(b)(2)(iiL (2) a copy of this Authorization Is as valid as an original, and (3) I have read and understand this Authorization.

21018772 • yt· D ·1101... .88S'1 I 70 PaploU

THIS IS NOT A REI.EASE OF a..AIM FOR DAMAGES.

Signature of Pitienf or Pir'sOnafRepresentative Date

Patient's Date of Birth J SOd8. i8CUi1ty NUmber

Diiaiption of Personal RepresentatiV8's Authority

(Reminder: Please return this entire form, Induellng the slgnatwa page.)

21078772 • Mr • 0.1105.8 ·1837 170 MMSN80I Pap3of3

~. AUTHORIZATION FOR DISCLOSURE OF

WAGE INFORMAnON TO USAA

I, 1ha Utdatsianed. as 1he employee or in my capacity as personal representative of 1he employee, ~~--.:o-~~-~--====-:~~_~~--- understand 1he Information obtained by 1hIs AuthorIzatIon will be uaed by JlSM casualty lRsuranqe COmpany CT1SAA. CIC) for 1ha purpose of verifying, evaluating, negotiating. and O1har pertinent legal uses. in comaction with my cfaim for banefItI or services on 1ha above identified Ios& I understand that ~ 1h1l authorization is voluntary, 11SAA. CJ:C . reserve. 1he right to dacontInue proceasing my claim if I refuse to srant thJa 1UthoriIaticn. and such refusal may be In breach of a policy ccndition if 1l'SAA - CIC reasonably needs 1h1t Aufhari&ation to adequately investigata my claim.

Although .. information released pursuant to this Authorlzation may no longer be protactacI by federal privacy ragulationl, any Information obtained wOI not be relaasad by USAA-ClC to any person or organization In .,., individually Identifiable form EXCEPT to its O1har affiliated property and casualty insur.ance CCIft1P81ies~ its relnsurar~ or othar persons or organizations performing business or legal services in comection with my claim. IncIuclng but not limited to subrogation and macrlCll bill review. or as may be o1harwiae perrtdtted or required by law. or as fur1her authorized by me.

I authorize anv firm or employer to furnish information about my position. job till, work history. nature of my wagaa, loa of ~ hour. and time lost from work as wall as any Information related to amounts paid or 41e under any sick leave plan, wage continuation plan or group hospital or accident banafit plan. including the identity nI adchss of 1ha Insurance carrier.

Thia AuIhorization shall be In forca and effect until1t&a claim ia concluded at which time 11118 Authorization to disclose fils information expires.

I understand that I may receive a copy of fila Authorization. and I haVe1he right to revoke 1his Authorization, In writing. at any time. I may request a copy or revoke1he Authorization by sending such wri\t8n request to _____ ---~---at 9800 Fredericlssburg lOad, San Antonio,," 78288. I understand that a revocation Ie not effective: (0 until receipt by uw· OlC • and (II to hi extant that USM -gc has relied on 1he usa or dllclosura of 1ha information.

I .... tttet a copy Of tIl'a AutfIortzatlon 'S a. valid .. an original. and that I have read and unc:Ierat8nd this AutMrlllltlon.

TtlS IS N:Tf A fIR EASE OF CLAIM FOR DAMAGES.

Employee: FRANK KING JR

Signature of enpaoyea or Personal Representative Date

Description of Personal Reprasentativa'1I AuthorIty (Proof of 1hIs """'1Iy must be returned wtlll UII8 AutIortZetIcl'l. WIIIout 1hIs proof, we WID not retv on UII8 AuUlartzal_)

51087.0705 MI • D·1105 ·8 ·1837 171

WAGE AND SALARY VlRlFICAnON

TO WHOM IT MAY CONCERN! AS a ...... t of I~es sustained In an autDmClblle accident on the date Indicated, the pet8Gft named below has applied fDr benefits under p ...... 'nlury p~ . It Is our undarstaridlng that this ,.... II or was ampIayed by .VUW' company. To .SIIat u~ n8 bIIft8iitS that mar be due. please provfde us wiIh this MIIIIS8II'y tNftPIo1ment ....... atIon. EMPL.OY&E'8 NAME

OCCUPA11ON J08 DESCRIPTION

DATES OF EMPLOYMENT I GROSS EARNINGS DURING 52 WHK PERIOD FROM: THROUGH: I PRIOR TO ACCIDENT $

UNGTH OF SERVICE

WAGE OR SALARY AS OF DATI OF ACCIDENT DATES ABSENT AS A RESULT OF ACCIDENT , ______ C PER HOUR FROM: ____________ __ THROUGH: _______ _

S C PERMEK F~: ____________ _ THROUGH: _______ _

$ C PERMONTH FROM: ____________ _ TH~H: _________ _

• C c::oMM1SS1OH FROM: ____________ _ THROUGH: _______ _

USUAL NUMBER OF HOURS WORKED PER DAY:

DI8A8IU'1'Y BEGAN:

TOTAL HOURS MISSED:

TOTAL NUM_R OF HOURS LOST:

USUAL NUMBER OF HOURS WORKED PER WEEK:

RETURNED TO WORK:

TOTAL DAYS MISSED:

WAS EMPLOYEI PAID DURING THIS ABSENCE? C VIS C NO IF "Ver, AMOUNT PAID: S _______ _

WAS PAYMENT A RESULT OF SICK LEAVE USED? C YES C NO

WHEN EMPLOYEE RETURNED TO WORK, WAS EMPLOYE! ABLE TO 'ERFORM AU RIOUIRED DimES? C YES C NO

IF NO. PLEASE DESCRIBE THE UM1TAnONS:

I8IMPLOYIIIHTITLID TO RlCEIYE BENEFITS UNDER A WAGE C YES IF 'YES'. AMOUNT PER WEEK OR fW.AINCONnNUA11ON PLAN? C NO PAID OR AVAILABLE: $ _____ PER MONTH

HAS IMPLDYEE RECEIVED. IS HIISHE RECEMNG. OR IS HEIIH! !NTITI.ED TO RECIIVEBINIEFITa UNDER WORKERS' COMPEN8A1'ION AS A RESULT OF TH18 ACCIDENT? C YES C NO C UNDETERMINED

IF "VEr. GIVE MAUl. ADDRESS. AND TELEPHONE NUMBER OF OOUPEN8A11ON CARRIER OR Ct.AIM REPRlSENTAnve: NAMI: TELEPHONE NO:

ADDRESS:

NAME OF EUPLOVER: ADDRESI: ___________________________________________________________ _

SlGNAlURI: __________________________ TELEPHONE NO.:

TITl!: DATE:

S'08M705 ., .. D·71. ... .8837 170

~. AUTHORIZATION TO PAY DIRECT

.1 Member Name I USAA Numllet I LJA Nvm1MIr I Data of LQ88

I hereby authorize payment of benefits under the Policy and the No-Fault Insurance Plan to be paid directly to all medical care providers for services rendered to me a8 a result of an accident which occurred on ---------INSURANCE COMPANY:

USAAfI:

NAIIE a ADDRESS OF INSURED:

NAME I ADDRESS OF PA'11Etrn

DA _______________ _ aGNA~R~ ______________________________ _

MI. D.7105 •• .1837 170

~. LIST OF PROVIDERS/EMPLOYERS

I Member Name I USAA Humbflr I UR Number I DafD of Lalla

INJURED PERSON: __________ _

PLEASE UST BELOW THE NAMES AND ADDRESSES OF ANY TREATING PROVIDERS/EMPLOYERS: NAMEOF~I~: ______________________________________________ _

ADDRESS

CITY, STAle, ZIP

PHONE NUMBER

FAX NUMBER

DESCRIBE TYPE OF TREATMENT BEING PROVIDED: ______________ _

NAME OF PROVIDER: ___________________________ _

ADDRESS

CITY, STAle, ZIP

PHONE NUMBER

FAX NUMBER

DESCRIBE TYPE OF TREATMENT BEING PROVIDED: __________________ _

NAMEOFEM~O~: __________________________________________ _

ADDRESS

CITY, STAlE. ZIP

PHONE NUMBER

FAX NUMBER

GIVE OCCUPATION AND OATES OF EMPLOYMENr

·USE BACK OF FORM FOR ANY ADDITIONAL INFORMATION.

PLEASE RETURN THIS FORM WITH YOUR SIGNED MEDICAL ANDIOR WAGE AUTHORIZATION OR PERSONAL INJURY PROTECTION APPLICATION FORMS.

Page 1 atl MI. D·lfOS .a S2775-0808

·1837 170

Date

MICHIGAN MOTOR VEHICLE NO-FAULT INSURANCE LAW ATTENDING PHYSICIAN'S REPORT

Our Policyholder Accident Date File Number

To assist us in determining benefits due under the Michigan Motor Vehicle No Fault Law, the attending physician must complete this report. You are required to provide this information in accordance with the Michigan Motor Vehicle No Fault Law, P.A. 294 of the Public Acts of 1972.

Patient's Name

Street, City, State, Zip Code

Age Occupation/.Job Description

History 0Mil")) 8nd~nFY as Desc7 bY7nl

Diagnosis and Concurrcnt Conditions ,

When did symptoms first appear? When did patient first consult you for this condition?

Hllve you treated patient before this date? If yes, whcn?

Has patient ever had same or similar condition? If' yes, state when lind dl'sl'ribe

!'atient was unablc to work: Il'stili disabled, paticnt should be able to rcturn to work on:

From: Througb: Dnle:

If patient was hospitalized, name of hospital Period of Hospitalization

From: To:

Is patient still undcr your care for this condition'! If' yes, indicate projected duration and frequcncy of trcatmcnt:

***REPORT OF SERVICES***

Attach itemized bills for this accident only, and include amounts paid or payable by other sources. Attach verification of payment or rejection.

IRSrrlN Identification Number Physicilln's Nnmc (Please Print)

Address I'hysic.illn's Signature

City. State. Zip Code

WORK DISABILITY CERTIFICATE

I, _________________ , have examined and/or treated (Name of Doctor)

__________________ for injuries sustained in a motor vehicle (Name of Patient)

accident that occurred on ---------------~-

(Date of Accident)

It is my opinion that, as a result of the injuries received in the motor vehicle accident, the aforementioned patient is:

Totally disabled from returning to work from ______ to _________ _

Partially disabled but may return to work only under the following work restrictions from to ----------

Sit-down job duties only. Right hand/arm job duties only. Left hand/arm job duties only. No prolonged sitting. Limited walking. No overhead reaching. No pushing, pulling, stooping or bending. No lifting. No lifting over lbs. Other restrictions: ---------------

Able to return to work without restrictions on ---------It is my opinion that the aforementioned patient is disabled from working due to

the following accident-related injuries/diagnoses: ______________ _

Doctor's Signature

Dated: -----------Doctor's Address

MICHIGAN MOTOR VEHICLE NO-FAULT INSURANCE LAW WAGE, SALARY AND BENEFITS VERIFICATfON

/0;\::'-- ---- -~ --r~r POlicyholder-- -------=~-------

~mPJovee'S Name

Accident Date

Social Security No

'SIIMt C'!v Slate. Zip Code

---_._- ._---- ...... _ .... __ ._-----_._-- .... -_ ..... _. __ .. _._--_ .. --_._--_._--

I File N~mber

The above named person has applied for benefits under the Michigan Motor Vehicle No-Fault Insurance Law as a result of injuries sustained in an automobile accident on the date indicated We understand this person is your employee or former employee To assist us in determining benefits that may be due this person, please provide us with the answers to the follow­!ng questions. You are required to provide this information In accordance with the Michigan Motor Vehicle No-Fault Insurance Law. P A 294 of the Public Acts of 1972.

Thank you lor your cooperation . __ ._._-.-.. _--------------------

Claim Departmp.nl

r-----------------------------------------------------------------------------~ 1 Job Tille and Description of Duties

f-----.- .. --.-.. --... ---------.. _ ... --.--.-------.----------" .. --.-.----.----.-----------------2 Dales 01 Employmenl· From Through

~--.------."--.,, .......... -.-.. --.... ----,,-----.---------.. -.. -------- .... ,,-.. - .... ------.-----.. --.-.. -.------l :3 Emptoyment Status o Full Time o teave of Absence

o Part-Time o Terminalion

o Seasonal

[J lay-Olf ~---------------------...:.....---'"-- -----------------·--------4

4 Circle days worked in average week: 5 M T W T F S

Hours worked per day: HOllIS worked pel week r------ ------------ -"'''' _ ... ----.... -.--------.. --.-.. -------4

5 Income earned last calendar year: $

1-----------------------------------.---------------.--, -.,--------.. "-6 Wages fJ Hourly $ (Includ£! COLA and shill premium) [] Salary $

_._------------_._---------------------------_._------------_._---------,,-7 Was employee working over lime at Ihe lime of disability? [] Yes o No

--._--,,-....... ---------.,-------.--",,--.------------------------------I ; a II yes. average hours 01 overtime per week' Rate Of pay for overtime $

0--- -------.--------.. - .. - .. - __________ .... _______________ . _____ --1

I 9 Dates absen! due to disability' I t __ .. From Through. --------_._-------------_.,,---_._-----_. 1'0 Did emptoyee's injury arise out 01 and In the course of his/hm employment? [J Yes [J No

L----------.-.. ------______________________ .. _. __________________ ,, __________ . ______ .. __ _ i 11 If yes. give name of workers' compensalion insurance carrier.

It--'2-'-s-e-m-p-1o-y-e-e-c-.. o-v-e-re--d-by-a-w-a-g-e-o-r-s-a-la-r-y-c-o-n-tl-nu-a-n-c-e-p-la-n-7---O-" --Y-~--O--N-o--------------·--- - ...... -.---.------.-----1

Ii " yes. give name and addless of provider 01 benefits and describe the nalure of the plan:

I Policy Number. ---------When do benefits begin? _________ _

Amount payable per week: $ _______ _

How long beneflts payable?

13 Is employee covered by a medical benefits plan? [] YE!S o No If yes give name and address of provider and policy number;

~_P.:::O~liC~y~N::.u~m:b:e:..f·_========= ____ . ___ . ________ ._._'" __ ._"' __________________________ --'

Dale __ '"'_' ._"" _ ----- _ •. _ .... ----D,ln! Name &. Tlllo

Signature

Phone

REPLACEMENT SERVICES DISABILITY CERTIFICATE $20.00 PER DAY MAXIMUM

I, _______________ , have examined and/or treated (Name of Doctor)

______________ , for injuries sustained in a motor vehicle accident (Name of Patient)

on ______________ __

(Date of Accident)

It is my opinion that as a result of the injuries received in this accident, the aforementioned patient is disabled from doing: (Please check all that apply)

1) "Housework" as some housework may involve bending, lifting, twisting, and prolonged standing as required by changing linens; making beds; washing floors, sinks, bathtubs, toilets; moving furniture; picking up objects off floor; carrying garbage, etc.

2) "Caring for patient's children" which may involve bending, lifting, twisting and prolonged standing as required by changing children's clothes; bathing children, cooking for children; feeding children; cleaning and straightening up after children, etc.

It is my opinion that the aforementioned patient (is)(was) disabled as described above

from __________ to ___________ . The patient needs help 7 days per week.

Doctor's Signature

Dated: -------------Address

HOUSEHOLD SERVICES STATEMENT

Client Name _________________________ _

Service Providers Name. _____________________ _

Service Providers Address ____________________ _

Social Security Number (last four digits) ________________ _

Describe specifically what services you provided:

A. Vacuuming G. Laundry M. Driving (destination & mileage B. Dusting H. Changing Linens N. Running errands (be specific) C. Cooking I. Snow Shoveling O. Child Care D. Dishwashing E. Making Beds

J. Grass Cutting K. Grocery Shopping

P Home Repairs(be specific) Q. Window Washing

F. Ironing L. Taking out Garbage R. Misc ...

Indicate on the following calendar what services by letter were formed on which dates: .i

MONTH

1. 2. 3. 4. 5. 6.

,

8. 9. 10. 11. 12. 13.

15. 16. 17. 18. 19. 20.

22. 23. 24. 25. 26. 27.

29. 30. 31.

I expect to be paid for these services.

Providers Signature: ____________ Date: _________ _

Insured Signature: ____________ Date: _________ _

7.

14.

21.

28.

TRANSPORTATION EXPENSE LOG

Name:

DOl:

Case No.:

ROUND TRtp -DATE FROM TO MILES

.

,

.

AnENDANT CARE DISABDJTY CERTIFICAIE

I, _________ .---JI, have examined andlortJeated

_____________ ', for injuries sustained in a motor vehide

accident on • It is my opinion that as a leSuit of the Injuries

received In this accident, the aforementioned patient needs help with aU or some

of the following:

-AcnvmEs OF DAILY UVING- such as Bathing; Dressing;

Ambulation; Styling/combing of hair; Help using the toilet;

Driving the patient: Cooking for the patient; Fetching things

for the patient; Carrying and lifting things for the patient,

Assisting with medication and Supervision for safety reasons.

II Is my opinion that the patient (islwas) disabled and in need of A1TENDANT

CARE as described above from _____ 10 ____ ~. The patient needs

help __ days each week at __ hours per day.

Docloi Sfiinature

Dated: Address

----

AFFIDAVIT OF ATTENDANT CARE SERVICES PERFORMED Name of Insured: Claim #: Date of Incident: Service Provider’s Name: Describe specifically what attendant care services were provided: A. Assistance with Hygiene B. Grooming C. Bathing D. Toileting E. Transferring/Positioning F. Physical Therapy Oversight

G. Eating H. Meal Preparation I. Medication Management J. Care of Health Equipment K. Management of Finances L. Wound Care

M. Safety Supervision N. ________________O. ________________P. ________________Q. ________________

On the following calendar, please indicate: (a) the services by letter; (b) the dates on which those services were performed; and (c) the number of hours required for performance of those services for each date.

Month: 1 Hours:

2 Hours:

3 Hours:

4 Hours:

5 Hours:

6 Hours:

7 Hours:

8 Hours:

9 Hours:

10 Hours:

11 Hours:

12 Hours:

13 Hours:

14 Hours:

15 Hours:

16 Hours:

17 Hours:

18 Hours:

19 Hours:

20 Hours:

21 Hours:

22 Hours:

23 Hours:

24 Hours:

25 Hours:

26 Hours:

27 Hours:

28 Hours:

29 Hours:

30 Hours:

31 Hours:

Total hours: Charge per hour: Total Due: Have you provided services prior to the accident? I expect to be paid for all services provided. I declare the above information to be true and accurate and above services were performed as indicated. ________________________________ (signature of party performing services) (date)

_________________________________ (signature of insured) (date)