Motor Vehicle Claim Request

Patient Information

First Name

Last Name

Date of Birth

Address

Phone

Date of Accident

Injured Body Part(s)

*** If multiple body parts, list all and include side (left or right)

Accident Information

Was this a motorcycle accident?

Yes

If motorcycle accident, are there medical benefits on the insurance policy?

Yes

Accident City/State

Insurance Information (this must be the patient's auto insurance policy)

Policyholder Name

Policy Number

Insurance Company

Claim Number

Claims Address

Adjuster Name

Adjuster Phone

Insurance Company

Member ID

Group ID

Claims Address

Back of Insurance Card

Policyholder Name

Policyholder/Subscriber - the person whose employer provides the policy as a benefit or person paying for the insurance premium

Patient's relationship to subscriber

Child

Self

Spouse

Other