Subrogation Questionnaire
Patient Information:
*
Patient's First Name
Patient's Last Name:
Date of Birth
-
Month
-
Day
Year
Patient's date of birth
Subrogation File #: (located on letter)
*
File number located on letter
Member ID #: (may also appear as BCBSM ID on letter)
ID #
PLEASE NOTE:
If the questionnaire is unrelated to an accident or injury where another insurance is involved, you must answer ‘NO’ to the next question below and select 'Submit'.
Has the patient recently been treated by a doctor for an accidental injury?
*
Yes
No
Was the patient treated for injuries related to: (check all that apply)
Auto Accident
Fall
Injury at Work
Personal Injury
Injury at Home
Motorcycle Accident
If motorcycle accident - were you wearing a helmet?
Other (please specify)
Date of Accident
*
/
Month
/
Day
Year
Select the date the accident occurred.
City of the accident
*
Add city in which accident occured.
State of the accident
*
Add state in which accident occured.
Did you file any type of claim against the liable party, other person or entity?
*
Yes
No
List names of any other covered dependents involved in the accident, if applicable:
Describe the accident or incident:
*
Enter types of injuries
Is anyone at fault?
*
Yes
No
If yes, who is at fault?
Enter name
Responsible insurance company, if not BCBSM:
Name
Address
City
State / Province
Postal / Zip Code
Adjuster (Agent) Name:
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Fax Number
Claim Number
Claim Number
Did you hire an attorney?
*
Yes
No
Attorney Information
Attorney Name
Address
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Fax Number
Email
example@example.com
Upload any applicable claim forms and other case related documentation here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: