Crash bill & coverage worksheet

Use this when talking with an insurer, billing office or your legal team.

Crash date Claim / reference number

Medical bills

Ask: Will you bill insurance or defer payment, and what will I owe?

Health plan / MedPay; lien provider terms, including what is owed without a recovery

Ask: What coverage, deductible and limits apply to this repair?

Insurer, policy / claim reference, repair estimate and answers

Ask: Can I see the itemized deductions and estimated amount payable to me?

Final bills, provider liens and other repayment claims to verify; count each obligation once

Copy amounts from statements. A listed balance is not necessarily the amount you owe.

Next step / person to contact / follow-up date

Print and write by hand, or fill in the fields before printing. Entries are not saved.