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1AllstateleT e m p o ra r yI n s u r a nc eFloridaA u t o m o b i l eIdentification C a r dlstateing o uA L L S T A T EF I R EA N DC A S U A L T YI N S U R A N C EC O M P A N YP O L I C YN U M B E R9 9 1 0 7 5 5 0 7 - 0 9 3 8 8E F F E C T I V ED A T E1 1 / 0 5 / 2 0 2 4It xrotnmtaN11otice, ard(Seou,pieasethebtwbaereprdPolr3id5aXla2w%,sizepaper.T e m p o r a r yP r o o fofI n s u r a n c eC a r d ( s )H e r earey o u rT e m p o r a r yProofofinsurancethatthanyour60dayscard(s)wilCard(s).Pleaseafterthenot"EffectivekeepbevalidinDate"mindmorelistedo nthecard(s).Wewills e n dy o up e r m a n e n tI Dcard(s)beforethattime.Please k e e pthet em po ra rycard(s)iny o u rvehicleuntily o u rp e r m a n e n tcard (s)arrive.Whenyou rp e r m a n e n tcardsarrive,pleasereplacetheset em p o r a r ycard(s)withthe p e r m a n e n tI Dcard(s)a n d thendestroythet em p o ra rycard(s).XP E R S O N A L I N J U R YP R O T E C T I O NXB O D I L YI N J U R YL IABILITYXPROPERTYDAM AGEL I A B I L I T YD I A N E B R O W N ,R O S A W I L S O N2 0 1 6C H E V YT R U C K S ,E Q U I N O X2 G N A L C E K 7 G 1 1 2 5 9 4 6N O TV A L I DM O R ET H A NO N E Y E A RF R O ME F F E C T I V ED A T E.【fy o uh a v ea na c c i d e n to rloss:G e tm e d i c a lattentionif n e e d e d . N o t i f y t h epol icei m m e d i a t e l y .O b t a i nn a m e s , a d d r e s s e s , p h o n en u m b e r s ( w o r k&h o m e ) a n dl icensep l a t e n u m b e r so fallp e r s o n si n v o l v e di n c l u d i n gp a s s e n g e r sa n dw i t n e s s e s .Call1 - 8 0 0 - A L L S T A T E ( 1 - 8 0 0 - 2 5 5 -7 8 2 8 ) , l o g o ntoa l l s t a t e . c o mo rc o n t a c ty o u ra g e n ta ss o o na s
p o s s i bl e .C L A U D I AT A L L O N3 0 0 0S W1 4 8 T HA V ES T E2 1 6M I R A M A R , F L3 3 0 2 71 ( 9 5 4 ) 9 0 8 - 2 7 0 0Ify o u carryA u t oCollisionI n s u r a n c e : R e n t a lc a rc o v e r a g e is p r o v i d e d , s e eoutlineo fc o v e r a g e .(T h i sm e a n sA u t oCollisionI n s u r a n c ewilla p p l ytoavehiclere n t e do nas h ort - t ermbas is ,notthaty o uwillb er e i m b u r s e dforthec o s to frentingasubstitutevehicle)M i s r e p r e s e n t a t i o no fi n s u r a n c eisafirstd e g r e em i s d e m e a n o r
R E T U R N T OW O RKF O R MC O P I E ST O :D I V I S I O NH E A DO R I G I N A L T O :H U M A NR E S O U R C E SPatient’sN a m e(last,first,middleinitial)D a t eofInjuryE m p l o y e rN a m e&AddressNatureofInjuryT OB EC O M P L E T E D B Y M E D I C A LR E P R E S E N T A T I V EIs a wa n dtreatedthispatiento n_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _a n db as edo nthenatureoftheinjury/illness1)[ ]Patientisfullycapabletop e r f o r mallassigneddutieswithn orestrictionsorlimitations2)[ ]Ir e c o m m e n dthee m p l o y e ereturntow o r kwithn olimitationsorrestrictionso n_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _D E G R E EL I M I T A T I O N S[]SedentaryW o r kLifting1 0p o u n d sm a x i m u ma n doccasionallyliftingand/orcarryings uc harticlesasdockets,ledgers,a n dsmalltools.A lt h o ug hasedentaryjobisdefinedaso n ew h i c hinvolvessitting,acertaina m o u n tofw al k i nga n dstandingisoftennecessaryincarryingoutjobduties.J obsaresedentaryifwalk inga n dstandingarerequiredon lyoccasionallya n dothersedentarycriteriaaremet.[]LightW o r kLifting2 0p o u n d sm a x i m u mwithfrequentliftingand/orcarryingofobjectsw e i g h i n gu pto1 0p ounds.E v e nt houg hthewe ig htliftedm a ybeonlyanegligibleam ou nt ,ajobisinthiscategoryw h e nitrequiresw a l k i n gorstandingtoasignificantdegreeorw h e nitinvolvessittingm o s tofthetimewithadegreeorpu shin ga n dpullingofa r mand/orlegcontrols.[]M e d i u mW o r kLifting5 0p o u n d sm a x i m u mwithfrequentliftingand/orcarryingofobjectsw e i g h in gu pto2 5pou nds .[]H e a v yW o r kLifting1 0 0p o u n d sm a x i m u mwithfrequentliftingand/or1.Inatypicalw o r kday,patientm a ya.S t a n d / W a l k[]N o n e[]1-4H r s[]6- 8H r s[]Un limit e db.Sit[]N o n e[]1-4H r s[]6- 8H r s[]Un limit e dc.Driv e[]N o n e[]1-4H r s[]6- 8H r s[]Unlimited2.Patientm a y useh a n d sforrepetitivetasks:[]Simp leG ra s pi ng[]FineMan ip u lat io n[]Pushing/Pulling3.Patientm a y usefeetforrepetitivem o v e m e n tasinoperatingfootcontrols:[]Y e s[]N o4.Patientisableto:FrequentlyOccasionally U n a b l ea.B e n d[][] [ ]b.Squat[][][]c.C l i m b[][] [ ]d.R e a c h[ ][][]O the rInstructionsand/orLimitations:4)T h e s erestrictionsr e m a inineffectuntil_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _oruntilpatientisreevaluatedo n_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _5)Thise m p l o y e eistotallyincapacitatedatthistimea n dwillb ereevaluatedo nM e d i c a lRepresentative’sN a m eT e l e p h o n eN u m b e rM e d i c a lRepresentative’sSignatureD a t eA U T H O R I Z A T I O NT OR E L E A S E I N F O R M A T I O NIhe reb yauthorizem yattendingphysicianand/orhospitaltoreleasethea b o v einformationorcopiesthereofacquiredinthecourseofm yexaminationortreatmentfortheinjuryidentifieda b o v etom ye mp lo ye rortheirrepresentative.Patient’sSignatureD a t e
AllstateA u t o m o b i l eI n s u r a n c eLkeethdt h.’o edt*looiIo a a d m d .N otifyth aa u c o aorc o n t a c ty o u ra g e n taas o o naa