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Each eligible individual wishing to apply for coverage must complete a separate application. Be sure to fill out both forms.Never write "01 - Killed" in column. (box) 86 (Victim's Physical Condition) for an injury crash. The importance of consistent, complete documentation in the medical record cannot be overemphasized. You should always complete this form when the insured or covered dependent suffers an accidental injury that results in a covered loss other than death. The principal responsibility of the medical examiner or coroner in death registration is to complete the medical part of the death certificate. Before. 5. Proper diabetes management and foot care help prevent complications that can result in amputation. NINDS offers a variety of tools and educational materials designed for health professionals involved in the treatment of acute stroke. For most lower extremity injuries, complete Form 4841, "Lower Extremity Range of Motion," in conjunction with the closing examination report. a. Amputation.