Interim Settlement Pack Form and Response to Interim Settlement ...

Interim Settlement Pack and Response to Interim Settlement Pack (RTA4)Low value personal injury claims in road traffic accidents (£1,000 - £25,000)Claimant request for interim payment numberClaimant’s full nameDefendant’s full nameClaimant’s representativeDefendant’s representativeDate of notification / / Date of insurer response / /Contact detailsFirm or Company nameContact detailsFirm or Company nameContact nameContact nameTelephone numberTelephone numberE-mail addressE-mail addressReference numberReference numberRTA4 Interim Settlement Pack and Response to Interim Settlement Pack (04.13)1

Interim settlement pack and responseClaimant losses to dateLossClaim itembeingpursuedEvidenceattached Comments Grossvalueclaimed%contributorynegligencedeductionsNet valueclaimedDefendant responseIs grossamountagreed?CommentsGross valueoffered%contributorynegligencedeductionsNet valueofferedAmount indisputeYes / No /N/APolicy excessLoss of useCar hireRepair costsFares (taxis, buses,tube, etc.)Medical expensesClothingCare/ServicesLoss of earningsa) Claimantb) EmployerOther lossesPSLADisadvantage onthe labour marketLoss of congenialemploymentFuture lossesTotal heads of netdamage claimed to dateLosses offered to dateCRU deductions2Net value of offer to date

Claimant request for interim paymentDefendant response to interim payment requestDate Value of interim request Date Value of interim payment agreed/ / / /Detail reasons for interim payment request belowAdditional comments belowStatement of truthI am the claimant’s legal representative. The claimant believesthat the facts stated in this claim form are true. I am dulyauthorised by the claimant to sign this statement.I am the claimant - I believe that the facts stated in this claimform are true.SignedDate/ /Position or office held(if signed on behalf of firm or company)I have retained a signed copy of this form including the statement of truth.3