Common Contracts
1 similar Subrogation Agreement contracts
Subrogation AgreementSubrogation Agreement • December 5th, 2011
Group # Insured ID # Today’s Date Date Of Injury Claimant Information Patient Name Street Address City/State/ZIP Accident/ Injury Information 1. Location of Accident Property Owner/Lessee Street Address City/State/ZIP 2. Accident Date: Nature of Accident: 3. Describe the Injury: 4. Will patient require future medical treatment because of these injuries? 5. Did the police investigate the accident? If YES, Please send copyof police report. Third Party Liability 6. Has a claim been made under any other insurance plan or against any other person orcompany as a result of this accident/injury? [ ] YES [ ] NO Comments: 7. If you answered "Yes" to question #6, please give name and address of party: Person's Name Company Street Address Street Address City/State/ZIP City/State/ZIP Insurance Company Street Address City/State/ZIP 8. Has any settlement been made? [ ] YES [ ] NO 9. Has any suit been filed? [ ] YES [ ] NO If Yes, When: Where: 10. If suit has not been filed, do you intend to
