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

VA Form 10-1023 is the U.S. Department of Veterans Affairs form titled Information Regarding Possible Claim Against Third Party. VA's form page lists it under VHA, the Veterans Health Administration. The form is a report: its TO block names District Counsel (02) at the address of the VA facility, and its FROM block holds the name and address of the VA facility sending it.

The report records a Veteran's details, the nature of an injury or disease, any reimbursable insurance, and any third party a claim or cause of action may be against, with boxes for tort-feasor, worker's compensation, crimes of personal violence and "no fault" insurance. It also asks about the incident, witnesses, any investigation and whether the Veteran has contacted an attorney.

The PDF is one page and prints no instructions, filing address or OMB number. You can fill out the PDF free in your browser on this page and download the result without an account.

Top of page 1 of VA Form 10-1023: Information Regarding Possible Claim Against Third Party, as printed by VA

What's on VA Form 10-1023

TO and FROM

The address block for District Counsel (02) at the VA facility, and the name and address of the VA facility sending the report.

Veteran and informant details

The Veteran's name, address, telephone and Social Security number, the date of the report, and the name, telephone and address of any other person furnishing the information.

Injury and insurance

The nature of the injury or disease, and any reimbursable insurance: company and address, policy number, type of coverage and whether it is group or individual.

Third party and type of claim

The name and address of the third party if the claim or cause of action is against one, checkboxes for tort-feasor, worker's compensation, crimes of personal violence and "no fault" insurance, and whether and to whom a claim was submitted.

Incident, witnesses and investigation

The date, time, exact location and description of the incident that resulted in injury, witnesses' names, phone numbers and addresses, and which authorities, if any, investigated.

Attorney and remarks

Yes or no for whether the Veteran has contacted an attorney, the attorney's name and address if applicable, and an open remarks box.

How to fill in VA Form 10-1023

1
Fill in the address blocks
Enter the address of the VA facility under District Counsel (02) in the TO block, and the sending VA facility's name and address in the FROM block.
2
Enter the Veteran's details
Add the Veteran's name (last, first, middle initial), address, telephone, Social Security number and the date of the report.
3
Describe the injury and coverage
Record the nature of the injury or disease, any reimbursable insurance, the third party if there is one, and check the type of claim.
4
Record the incident
Give the date, time, exact location and description of the incident, witnesses and any authorities that investigated it.
5
Add attorney details and remarks
Answer the attorney question, add the attorney's name and address if applicable, and use the remarks box for anything else.

The PDF has no instruction page. These steps follow the order of its boxes.

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Where it goes

Addressee

The form's TO block names District Counsel (02) at the address of the VA facility. The PDF prints no mailing address of its own.

No printed instructions

The one-page PDF has no instruction page, help line, OMB number or Privacy Act notice. VA's form page lists no online tool.

Edition

The PDF footer reads VA FORM JUNE 2007, and VA's form page gives a form revision date of June 2007.

Who uses VA Form 10-1023?

The VA facility sending the report
The FROM block asks for the name and address of the VA facility, and the form has a box for the date of this report.
District Counsel, who receives it
The TO block is printed with District Counsel (02) and a space for the address of the VA facility.
The Veteran the report is about
The form records the Veteran's name, address, telephone and Social Security number, and asks whether the Veteran has submitted a claim orally or in writing.
Another person giving the information
When the information comes from someone other than the Veteran, the form asks for that person's name, telephone and address.
An attorney, if there is one
The form asks whether the Veteran has contacted an attorney and, if applicable, the name and address of the attorney representing the Veteran.

The form does not print instructions. Its labels show who sends it, who receives it and whose information it holds.

Official sources and the blank

Official VA form page
The agency’s own page for Form 10-1023.
Blank PDF
The official blank form, to print or fill by hand.

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Questions about Form 10-1023

What is VA Form 10-1023 used for?

It reports information regarding a possible claim against a third party connected with a Veteran's injury or disease. The form is addressed from a VA facility to District Counsel (02).

Who completes VA Form 10-1023?

The form does not say in words. Its FROM block holds the name and address of the VA facility, and it records information from the Veteran or from another person furnishing it.

What types of third party claims does the form list?

It has checkboxes for tort-feasor, worker's compensation, crimes of personal violence and "no fault" insurance.

Does VA Form 10-1023 have a signature line?

No. The PDF has no signature or certification box. It ends with a remarks box.

Is there an online version?

VA's form page lists no online tool for VA Form 10-1023, only the downloadable PDF.

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