Claim Form - Foreign Object in Food

This Claim Form for Foreign Object in Food is used by an individual who has suffered this type of injury or by an attorney representing a client. This claim form will serve as formal notice to a restaurant or grocery that food purchased at their location contained an unknown object. This claim form contains the pertinent information including where the injury occurred, if treatment was rendered and names of treating physicians. It also includes a short description of how this injury has affected the injured party's life. It is imperative that the details regarding this type of injury be set out in writing. A written Claim Form after eating food containing a foreign object will act as formal notice of a claim and be important in the event of litigation.

This Claim Form – Foreign Object in Food includes the following:

• Business: Sets out the name and address of the business or restaurant where the injury occurred;
• Injury: Detailed description of the incident including date, type of food and the location of the business or restaurant;
• Treating Hospital/Physician or Dentist: Description of the treatment received, name of physician or dentist, medications prescribed and follow-up instructions;
• Follow-Up Treatment: Any follow-up doctor or dental visits after the injury;
• Description of Injured Party: A synopsis setting out how the injury has changed the injured party’s life;
• Demand for Damages: Demand for damages including payment for lost wages and medical expenses;
• Signature: The claim form must be signed by the attorney or individual who suffered the injury.

This attorney-prepared packet contains:

1. General Information and Checklist
2. Claim Form – Foreign Object in Food

State Law Compliance: This form complies with the laws of all states

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• Includes:

  √ Free Checklist

• State:

   All
  

  Number of Pages:

   5

• File Types Included:

  
  √ Microsoft Word
  √ Adobe PDF
  √ WordPerfect
  √ Rich Text Format
  

• Compatible with:

  Windows and Mac OS