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Questionnaire

Accident questionnaire


All fields are required unless marked optional. Use "unknown" if you don't know an answer.

You can find this 8 character reference number at the top of your letter from us.
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Policy Holder

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Patient

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How should we contact you?

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Third Party

I was injured at work.
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Someone else was at fault for an injury I sustained within the past 2 years.
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If you are unsure whether the care was due to an accidental injury where another person, employer or insurance company may be responsible for payment of the medical services, please call us at 1-800-645-9785.