Accident Questionnaire Form printable pdf download

Subrogation / Workers’ Compensation

I-20 at Alpine Road

Columbia, SC 29219-0001

1-800-288-2227, extension 43060

Fax: 1-803-865-0654

ACCIDENT QUESTIONNAIRE

Subscriber:

Patient:

Address:

Identification No.:

Address:

Provider:

Date of Service:

Group Number:

Claim Number:

Claim Amount:

Dear Member:

Our review process indicates this patient may have received healthcare services related to an accident. So we may evaluate our

responsibility, please complete, sign and return this form within five days of receipt. If we do not receive this information, we may

have to deny your claims. If you have previously completed a form for this accident, please check here _____ and update.

Auto/Motorcycle Accident_____Work Related_____Other Accident_____No Accident

Was the injury or illness:

Date of the injury or illness: ______________________

City/County and State of Injury: ______________________________

Describe the injury or illness and how it happened:

Names of other family members injured:

If you checked “Auto/Motorcycle Accident” or “Other Accident,” please answer the following:

Did another person cause this accident?

YES / NO

If yes, name and address of person causing injury:

Insurance Company of person causing injury:

Policy/Claim # :

Address and Phone #:

Adjuster’s Name:

If auto or motorcycle related, was the patient wearing a seatbelt? YES / NO a helmet? YES / NO

If auto or motorcycle related, was the patient the driver _________ or a passenger _________ ?

Auto Insurance Company of Patient:

Policy/Claim #:

Address and Phone #:

Adjuster’s Name:

If you checked “Work Related,” please answer the following:

Name and address of patient’s employer at the time of injury:

Have you filed a Workers’ Compensation claim?

YES / NO

If yes, name of Workers’ Compensation carrier:

Policy/Claim # :

Adjuster’s Name:

Address and Phone #

Has the employer or the workers’ compensation carrier accepted or denied liability?

ACCEPTED / DENIED

Name, address, and telephone number of your attorney (if applicable): __________________________________________________

___________________________________________________________________________________________________________

I agree that the above information is correct, and I will not settle a claim before contacting the Subrogation / Workers’

Compensation Department of BlueCross BlueShield of South Carolina.

____________________________________________________________________________________________________________

Signature

Date

Telephone Number

Accident Questionnaire Form

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