Trailblazer Services Subrogation Request Form

Subrogation Request Form

Please take a moment to fill out this request form. Requests will be sent out within 24 hours, except in cases where the date of injury is recent; in such instances, they will be sent out two weeks from the date of injury.
Please utilize this Jotform for all Subrogation Requests.

For Medical Records, Medical Billing, and Balance Verification requests please click HERE.
Today's Date

MonthDayYear
Date
Firm Name
Requester Name*
Requester Email*
example@example.com

Injured Party Information

Please enter all fields
Client First Name*
Client Last Name*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN*
Date of Injury*

MonthDayYear
Date
Details of the incident of claim and injuries sustained*
Optional: List the treating providers for the incident
This information is used to crosswalk the subro lien
Is the client done treating?*
Enter last date of treatment, if client is done treating

MonthDayYear
Date
Insurance Information

Insurance Provider is required. Address and phone number are optional. If you don't know it, please write N/A
Insurance Information*
Settlement Information

Settlement Information is required if you are requesting a final subrogation amount.
Settlement Information
Comments

Please upload Authorization/DL/Insurance Card (front and back)/Other Documents*

Cancelof
Should be Empty:

Subrogation Request Form