Subrogation Questionnaire – Law Office of Bryan Davenport

1. Your Name (required) *

2. Your Email (required) *

3. Injured Party(required) *

4. File Number From Letter Received (required) *

5. Employee ID#(required) *

6. Group # (required) *

7. Name of Employer (required) *

8. Date of Accident(required) *

9. Please provide the details of the injury/accident (how did it occur):

10. Injury occurred at:

My Own Home
Work (Please answer #11 & 12)
Motor Vehicle (Please answer #13 & 14)
Other (Please answer #15-17)

11. If "Work" is chosen, please provide us with the injured party's employer's name.

12. If "Work" is chosen and a worker's compensation claim is being pursued, please provide:

WC Carrier Name

Ajuster Name & Phone Number

Insurance Policy/Claim Number

13. If "Motor Vehicle Accident" was chosen, please provide your auto insurance carrier information. Please provide:

Auto Carrier Name

Adjuster Name & Phone Number

Insurance Policy/Claim Number

14. If "Motor Vehicle Accident" was chosen and someone other than the injured party was at fault, please provide:

Name

Auto Insurance Carrier Name

Adjuster Name & Phone Number

Insurance Policy/Claim Number

15. Please provide exact location of injury (include street & #, city and state) and if known, the property owner's name.

Street Address or Street Name

City

State

Zip Code

16. If "Other" is chosen and you are pursuing an insurance claim with the property owner, please provide:

Property/Homeowner's Insurance Carrier Name

Associated Policy/Claim Number

17. If "Other" is chosen and you are NOT pursuing a claim with the property owner's insurance carrier, please provide us with a brief description as to why you are not pursuing the matter.

18. If you are represented by an attorney for this injury, please provide:

Name

Phone Number & Fax Number

Address

19. Date (required) *

20. File Upload

Click or drag a file to this area to upload.

Attach an accident report or other related documents

21. By typing my name below, I hereby certify that the information I have given is true and accurate. (required) *

I declare that the above information is correct and true and is the basis under which benefits are provided under this Plan. I authorize release of any information which may be necessary in determining benefits payable under this Plan. I have read and agree to abide by the Third Party Recovery Provision of the Plan contained in the Summary Plan Description. I hereby authorize for the sole purpose of subrogation/refund recovery issues, prior to or after payment, the release and receipt between any insurance company, organization or provider of service and the Law Office of Bryan B. Davenport, P.C. of any and all information related to this claim. I may revoke this authorization at any time by sending a written request to the Law Office of Bryan B. Davenport, P.C. at the address below. I agree to abide by the terms of the welfare health plan advancing the benefits.

Printed Name (required) *

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