VA Form 10-1023 Information Regarding Possible Claim Against Third Party

VA Form 10-1023 or the "Information Regarding Possible Claim Against Third Party" is a form issued by the U.S. Department of Veterans Affairs.

Download a PDF version of the VA Form 10-1023 down below or find it on the U.S. Department of Veterans Affairs Forms website.

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INFORMATION REGARDING POSSIBLE CLAIM
AGAINST THIRD PARTY
NAME AND ADDRESS OF VA FACILITY
ADDRESS OF VA FACILITY
District Counsel (02)
TO
FROM
(Last, First, Middle Initial)
TELEPHONE
VETERAN'S NAME
(Number, Street, City, State, Zip Code)
SOCIAL SECURITY NUMBER
VETERAN'S ADDRESS
DATE OF THIS REPORT
(Last, First, Middle Initial)
NAME OF PERSON FURNISHING THIS INFORMATION, if other than veteran
TELEPHONE
(if other than veteran)
ADDRESS OF PERSON FURNISHING THIS INFORMATION
NATURE OF-INJURY OR DISEASE
(INSURANCE COMPANY + ADDRESS, POLICY NUMBER: TYPE OF COVERAGE: GROUP OR INDIVIDUAL)
REIMBURSABLE INSURANCE
IF CLAIM OR CAUSE OF ACTION IS AGAINST A THIRD PARTY; GIVE NAME AND ADDRESS OF SUCH PARTY
TORT-FEASOR
CRIMES OF PERSONAL VIOLENCE
WORKER'S COMPENSATION
"NO FAULT" INSURANCE
HAS VETERAN SUBMITTED CLAIM
IF SUBMITTED TO THAN THIRD PARTY NAMED ABOVE, TO WHOM AND WHEN WAS IT SUBMITTED
ORALLY OR IN WRITTING
YES
NO
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
(if applicable)
HAS VETERAN CONTACTED ATTORNEY
NAME AND ADDRESS OF ATTORNEY REPRESENTING VETERAN
YES
NO
REMARKS
10-1023
VA FORM
JUNE 2007
INFORMATION REGARDING POSSIBLE CLAIM
AGAINST THIRD PARTY
NAME AND ADDRESS OF VA FACILITY
ADDRESS OF VA FACILITY
District Counsel (02)
TO
FROM
(Last, First, Middle Initial)
TELEPHONE
VETERAN'S NAME
(Number, Street, City, State, Zip Code)
SOCIAL SECURITY NUMBER
VETERAN'S ADDRESS
DATE OF THIS REPORT
(Last, First, Middle Initial)
NAME OF PERSON FURNISHING THIS INFORMATION, if other than veteran
TELEPHONE
(if other than veteran)
ADDRESS OF PERSON FURNISHING THIS INFORMATION
NATURE OF-INJURY OR DISEASE
(INSURANCE COMPANY + ADDRESS, POLICY NUMBER: TYPE OF COVERAGE: GROUP OR INDIVIDUAL)
REIMBURSABLE INSURANCE
IF CLAIM OR CAUSE OF ACTION IS AGAINST A THIRD PARTY; GIVE NAME AND ADDRESS OF SUCH PARTY
TORT-FEASOR
CRIMES OF PERSONAL VIOLENCE
WORKER'S COMPENSATION
"NO FAULT" INSURANCE
HAS VETERAN SUBMITTED CLAIM
IF SUBMITTED TO THAN THIRD PARTY NAMED ABOVE, TO WHOM AND WHEN WAS IT SUBMITTED
ORALLY OR IN WRITTING
YES
NO
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
(if applicable)
HAS VETERAN CONTACTED ATTORNEY
NAME AND ADDRESS OF ATTORNEY REPRESENTING VETERAN
YES
NO
REMARKS
10-1023
VA FORM
JUNE 2007

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