[Code of Federal Regulations]
[Title 33, Volume 1]
[Revised as of July 1, 2001]
From the U.S. Government Printing Office via GPO Access
[CITE: 33CFR25.117]

[Page 95]
 
                TITLE 33--NAVIGATION AND NAVIGABLE WATERS
 
          CHAPTER I--COAST GUARD, DEPARTMENT OF TRANSPORTATION
 
PART 25--CLAIMS--Table of Contents
 
                           Subpart A--General
 
Sec. 25.117  Proof of amount claimed for personal injury or death.

    The following evidence must be presented when appropriate:
    (a) Itemized medical, hospital, and burial bills.
    (b) A written report by the attending physician including:
    (1) The nature and extent of the injury and the treatment,
    (2) The necessity and reasonableness of the various medical expenses 
incurred,
    (3) Duration of time injuries prevented or limited employment,
    (4) Past, present, and future limitations on employment,
    (5) Duration and extent of pain and suffering and of any disability 
or physical disfigurement,
    (6) A current prognosis,
    (7) Any anticipated medical expenses, and
    (8) Any past medical history of the claimant relevant to the 
particular injury alleged.
    Note: An examination by an independent medical facility or physician 
may be required to provide independent medical evidence against which to 
evaluate the written report of the claimant's physician. The settlement 
authority determines the need for this examination, makes mutually 
convenient arrangements for such an examination, and bears the costs 
thereof.
    (c) All hospital records or other medical documents from either this 
injury or any relevant past injury.
    (d) If the claimant is employed, a written statement by the 
claimant's employer certifying the claimant's:
    (1) Age,
    (2) Occupation,
    (3) Hours of employment,
    (4) Hourly rate of pay or weekly salary,
    (5) Time lost from work as a result of the incident, and
    (6) Claimant's actual period of employment, full-time or part-time, 
and any effect of the injury upon such employment to support claims for 
lost earnings.
    (e) If the claimant is self-employed, written statements, or other 
evidence showing:
    (1) The amount of earnings actually lost, and
    (2) The Federal tax return if filed for the three previous years.
    (f) If the claim arises out of injuries to a person providing 
services to the claimant, statement of the cost necessarily incurred to 
replace the services to which claimant is entitled under law.