Assured Benefits Administrators Incident Questionnaire
Name of the Primary Plan Participant
*
First Name
Last Name
Member ID
*
Shown on the ID card
Name of the Member for whom the Incident Questionnaire is being completed
*
First Name
Last Name
Date of Birth of the Member for whom the Incident Questionnaire is being completed
*
-
Month
-
Day
Year
Member Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
Instructions for Completing
Complete section 1 & 2 if incident was not caused by another party. Complete sections 2, 3 & 4 if incident involved in a motor vehicle accident. Complete sections 2 & 5 if incident occurred at a place of residence. Complete sections 2, 4 & 6 if it was another type of incident caused by another third party
SECTION 1: COMPLETE IF INCIDENT WAS NOT CAUSED BY ANOTHER PARTY
I certify that the claim resulting from the following incident was not caused by another party.
Signature
Date
/
Month
/
Day
Year
SECTION 2: INCIDENT DETAILS
Date Incident Occured
*
/
Month
/
Day
Year
Place Incident Occured
*
Explanation of How Incident Occurred:
*
SECTION 3: COMPLETE IF THE INCIDENT WAS A MOTOR VEHICLE ACCIDENT
PLEASE ATTACH A COPY OF THE PEACE OFFICER ACCIDENT REPORT AND A COPY OF YOUR AUTO INSURANCE CARD OR POLICY AND REPLY TO THE FOLLOWING QUESTIONS.
Name of Individual at Fault, if other than yourself of your dependents
Address of Individual at Fault
Name of Auto Insurance Company of Individual at Fault
Insurance Policy Number of Individual at Fault
Insurance Company Telephone Number of Individual at Fault
Name of your personal Auto Insurance Company
Your Insurance Policy Number
Your Insurance Company Telephone Number
Will you be taking legal action?
Please Select
Yes
No
SECTION 4: COMPLETE IF YOU WILL BE TAKING LEGAL ACTION
Name of your Attorney
Address of your Attorney
Telephone Number of your Attorney
SECTION 5: COMPLETE IF THE INCIDENT OCCURED AT YOUR PLACE OF RESIDENCE
Name of Homeowner's or Renter's Insurance Company
If you do not have a Homeowner's or Renter's Policy, initial below.
I CERTIFY THAT I DO NOT HAVE A HOMEOWNER AND/OR RENTER’S POLICY IN FORCE.
SECTION 6: COMPLETE IF THE INCIDENT WAS ANOTHER TYPE OF INCIDENT AND CAUSED BY THE NEGLIGENCE OF A THIRD PARTY
Name of Company or Individual at Fault
Address of Company or Individual at Fault
Telephone Number of Company or Individual at Fault
Name of Insurance Company of Company or Individual at Fault
Policy Number of Insurance Company of Company or Individual at Fault
Insurance Company Telephone Number
Will you be taking legal action?
Please Select
Yes
No
If Yes, please complete Section 4
Primary Plan Participant Signature
*
Primary Plan Participant Social Security Number
*
Today's Date
*
/
Month
/
Day
Year
Date
For Motor Vehicle Accident, upload Accident Report and Proof of Insurance
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