Accident Information Request

Accident Information Request
Date

MonthDayYear
Date
Submission Guidelines:

Please fill out this form completely in order to ensure your claims are processed in a timely manner.

Fill in everything you know now. If you need to update or add details later, send another form.

Use the Member ID number and Group number found on the front of your membership card. Please see example ID card below.
Member
Name*

First NameLast Name
Member ID*
Client
Group Name*
Group Number*
First Num Group Number
Patient
Name*

First NameLast Name
Description of Injury(s)*
Claim Number
Your plan has a provision which states that any medical expense incurred as a result of an accidental injury caused by a third party must be reimbursed to the plan by the responsible party, the responsible party's insurance company, or through any settlement received by the injured party.

Please complete this form to the best of your ability, digitally sign it and use the submit button to return to our office. Claims for you or your dependent have been denied pending receipt of this questionnaire.
The treatment was due to one or more of the following (mark all that apply):*

Motor Vehicle AccidentOccupational Injury/Accident at WorkProduct LiabilityMedical MalpracticeSlip and Fall on another person's propertyInjury at homeOther condition - Examples include chronic pain,arthritis, illnessOther injury - Examples include animal attacks, injury at school, sports, etc
Product Liability - Have you filed a claim against a manufacturer?*

YesNo
Medical Malpractice - Have you filed a claim against anyone?*

YesNo
Slip and Fall on another person's property - Have you filed a claim against anyone?*

YesNo
Injury at home - Do you own or rent the property?*

RentOwn
Injury at home - Have you filed a claim against anyone?*

YesNo
Are you still being treated for this injury/illness?*

YesNo
Do you have an attorney handling your injury case?*

YesNo
Provide details - Date of injury, description and how you were injured:*
For inquiries related to this request, contact our Customer Service Department.

I hereby acknowledge and agree to the terms of my plan's subrogation, reimbursement and/or third party recovery provision(s). I authorize the release of medical information relating to this incident to my plan administrator.
Date

MonthDayYear
Date
Signature of Patient*

Clear
Please sign with mouse or finger if on mobile device.
Phone Number*
Please enter a valid phone number.
- In which city and state did the injury occur?
- Date of injury
  
  MonthDayYear
  Date
- Did you file a claim?
  
  YesNo
- If Yes, who did you file a claim against?
- Claim Number
- Insurance Carrier
- Adjuster Name
  
  First NameLast Name
- Adjuster Phone Number
  Please enter a valid phone number.
- Adjuster Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Number of vehicles in accident:*
- Was a police report filed?*
  
  YesNo
- Please include a copy of the report:
  
  Please note: The uploaded file must be DOC, DOCX, PDF, GIF, JPG, PNG, TIFF or TIF in format. The uploaded file must be less than 28MB in size. Renaming a non-supported file type to a supported file types will not be accepted. EXAMPLE: myreceipt.png to myreceipt.pdf
  Cancelof
- Name(s) of people injured in accident:*
- Are other people injured also members of this healthplan?*
  
  YesNo
- If yes, provide name(s):*
- Location of accident:*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Was anyone else at fault?*
  
  YesNo
- Did you file a claim?*
  
  YesNo
- If yes, provide claim number:*
- Your Automobile Insurance Information:
- Driver Name*
  
  First NameLast Name
- Owner Name *
  
  First NameLast Name
- Your and/or Owner's Auto Insurance Company:*
- Claim Number *
- Adjuster Name*
  
  First NameLast Name
- Adjuster Phone Number*
  Please enter a valid phone number.
- Adjuster Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- **You must attach documentation from your auto carrier indicating the auto policy/coverage in effect.
  
  Please note: The uploaded file must be DOC, DOCX, PDF, GIF, JPG, PNG, TIFF or TIF in format. The uploaded file must be less than 28MB in size. Renaming a non-supported file type to a supported file types will not be accepted. EXAMPLE: myreceipt.png to myreceipt.pdf
  Cancelof
- Other Driver(s) Automobile Insurance information:
- Other Driver's Name*
  
  First NameLast Name
- Auto Insurance Company*
- Adjuster Name*
  
  First NameLast Name
- Adjuster Phone Number*
  Please enter a valid phone number.
- Adjuster Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Did you file a Workers' Compensation claim?*
  
  YesNo
- Claim Number*
- Was the claim approved?*
  
  YesNo
- If No, are you appealing the denial?*
  
  YesNo
- Employer's Name*
  
  First NameLast Name
- Employer's Phone Number*
  Please enter a valid phone number.
- Adjuster Name*
  
  First NameLast Name
- Insurance Company*
- Insurance Phone Number*
  Please enter a valid phone number.
- Insurance Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- **If workers' compensation carrier denied your claim, provide denial letter.
  
  Please note: The uploaded file must be DOC, DOCX, PDF, GIF, JPG, PNG, TIFF or TIF in format. The uploaded file must be less than 28MB in size. Renaming a non-supported file type to a supported file types will not be accepted. EXAMPLE: myreceipt.png to myreceipt.pdf
  Cancelof
- Name*
  
  First NameLast Name
- Firm Name*
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number*
  Please enter a valid phone number.
- Email*
  example@example.com
- Settlement
- If you filed a claim for any reason, did you receive a settlement?*
  
  YesNo
- Settlement Date*
  
  MonthDayYear
  Date
- Settlement Amount*
- Date
  
  MonthDayYear
  Date
- Signature*
  
  Clear
- Please enter a valid group number.
- Should be Empty:

Accident Information Request

Member

Client

Patient

Your Automobile Insurance Information:

Other Driver(s) Automobile Insurance information:

Settlement