Subrogation | Injury Report

Subrogation Injury Report

Thank you for submitting your form online.

PLEASE NOTE: Dean Health Insurance is not able to pay any claims pertaining to this incident until you complete and return this questionnaire within 10 days from the receipt of this letter. Thank you for your cooperation.

Date Of Submission
06/05/2023

Member Number

Member Last Name

Member First Name

Date Of Birth

Date Of Service

1) Was your injury due to an accident?
Yes No

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

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

4) Are you pursuing a claim?
Yes No

5) Type of Accident:

6) Please write the details of your accident and injuries:

7) Name and address of person or establishment at fault:

8) Name and address of Insurance Company of person or establishment at fault:

Claim/Policy Number:

Adjuster’s Name:

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

Claim/Policy No:

10) If motor vehicle accident, how many vehicles involved?

If a single car accident, were you the driver?
Yes No

11) If motor vehicle accident, please list all names of passengers:

Work #:

Home #:

12) If you have retained an attorney, please state the name, mailing address, and telephone number:

Phone Number: