Continuum Recovery Services Insurance Verification Form

Insurance Verification
Name of Person Completing Form *
Phone Number of Person Completing Form *

Area Code Phone Number
Client Full Name *
Client Date of Birth *
(mm/dd/yyyy)
Primacy Policy Holder Information
Primary Policyholder's Full Name (if applicable)

First Name Last Name
Primary Policyholder's Date of Birth (if applicable)
Insurance Company *
Policy Number *
Group Number (if applicable)
Insurance Telephone Number

Area Code Phone Number

Address of Policyholder *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty: