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Accident/Incident Claim Form

Your Name:
How do you want to be contacted:
No response Needed
Email     Telephone     Fax
Email:
Telephone:
Fax #:

Patient Information

*Claim is on:

Employee    Spouse
Dependent

*Patient's Name:
*Patient's DOB:

Employee Information

*Employer Group Name:
*Employee ID#:
*Last Name:
*First Name:
*Address:
*City, State, Zip:

Physician Information

*Physician Who Treated the Injury:
*Physician's Address:
*Phone:
*Diagnosis:

Injury Information

*Date of Injury:
*Will you file a claim under Workman's
Compensation or similar law? 		Yes     No
*Where did the injury occur:
At work     At home
Other, please specify below:
Was Injury Work Related? Yes     No
*Give complete description below of
HOW and WHERE injury occurred:
What were you doing
the time the injury occurred:
*Is the injury due to
an automobile accident? 		Yes   No
*Was another party at fault? Yes   No
*If yes, give name and address
of other party at fault below:

Appeal Information

Check this box if you are appealing claims that have been denied for receipt of this information.

Other Insurance Information

*Has this claim been filed with
another insurance company? 		Yes     No
*Other company name:
*Other company address:
Other company city, state, zip:
Other company phone number:
Verification
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we've added visual verification to our contact form.
Please enter the code you see in the box to the left.