Subrogation | Injury Report

Subrogation Injury Report

Thank you for submitting your form online.

PLEASE NOTE: We are not able to pay any claims pertaining to this incident until you complete and return this questionnaire.
We appreciate your cooperation.

If you have any questions, please contact the Subrogation Department at 800-356-7344 ext. 4136 or 608-827-4136.

Date of Submission: 12/04/2023

Member Number

Member First Name

Member Last Name

Date Of Birth

Date Of Service

Work Phone #

Home Phone #

1. Was your injury due to an accident?

2. In which state did the incident take place in?

3. What was the date of your accident/injury?

4. Type of Accident

5. Please write the details of your accident and injuries

6. Name and address of person or establishment at fault

7. Name and address of Insurance Company of person or establishment at fault

7a. Claim/Policy Number

7b. Adjuster’s Name and Phone Number

8. Name and address of your insurance company (e.g. auto, homeowners, etc)

8a. Claim/Policy Number

8b. Adjuster’s Name and Phone Number

9. If motor vehicle accident, how many vehicles involved?

9a. If a single car accident, were you the driver?

10. If motor vehicle accident, please list all names of passengers

11. If you have retained an attorney, please state the name, mailing address, and telephone number