Free VA Form 10-1023 - Information Regarding Possible Claim Against Third Party fillable Stock #F01399 - Federal

INFORMATION REGARDING POSSIBLE CLAIM AGAINST THIRD PARTY
ADDRESS OF VA FACILITY

District Counsel (02) TO

NAME AND ADDRESS OF VA FACILITY

FROM

VETERAN'S NAME (Last, First, Middle Initial) VETERAN'S ADDRESS (Number, Street, City, State, Zip Code)

TELEPHONE

SOCIAL SECURITY NUMBER

DATE OF THIS REPORT NAME OF PERSON FURNISHING THIS INFORMATION, if other than veteran (Last, First, Middle Initial) ADDRESS OF PERSON FURNISHING THIS INFORMATION (if other than veteran)

TELEPHONE

NATURE OF-INJURY OR DISEASE

REIMBURSABLE INSURANCE (INSURANCE COMPANY + ADDRESS, POLICY NUMBER: TYPE OF COVERAGE: GROUP OR INDIVIDUAL)

IF CLAIM OR CAUSE OF ACTION IS AGAINST A THIRD PARTY; GIVE NAME AND ADDRESS OF SUCH PARTY

TORT-FEASOR WORKER'S COMPENSATION HAS VETERAN SUBMITTED CLAIM ORALLY OR IN WRITTING YES NO

CRIMES OF PERSONAL VIOLENCE "NO FAULT" INSURANCE IF SUBMITTED TO THAN THIRD PARTY NAMED ABOVE, TO WHOM AND WHEN WAS IT SUBMITTED

NAME, TELEPHONE NUMBER AND ADDRESSES OF WITNESSES

GIVE DATE, TIME, EXACT LOCATION AND DESCRIPTION OF INCIDENT WHICH RESULTED IN INJURY

WHAT AUTHORITIES, IF ANY, CONDUCTED INVESTIGATION OF INCIDENT

HAS VETERAN CONTACTED ATTORNEY YES REMARKS NO

NAME AND ADDRESS OF ATTORNEY REPRESENTING VETERAN (if applicable)

VA FORM JUNE 2007

10-1023