Subrogation Questionnaire
Thank you for using our online questionnaire.
Other ways to send us your information:
If you prefer not to send your information online, or are having trouble doing so please:
- Complete the printed form you received and mail it back to us in the provided envelope.
- Call us at 866-891-7397. One of our representatives can take your information by phone.
- For assistance in Spanish, please click here.
Please provide the following information as shown on your paper questionnaire.
- 1. Start
- 2. Injury / Illness Questionnaire
- 3. Incident Details
- 4. Signature Verification
Injury / Illness Questionnaire
* indicates a required field.
*Was the medical care on the date of service listed on your questionnaire related to any of the following?
Please choose the option that best applies.
Injury / Illness Details
Before you proceed, you may want to have any auto insurance, workers’ compensation insurance or other liability insurance information and your claim number(s) available that are related to your injury.*Please enter a valid date.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
*Please enter a valid date.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
*Please enter a valid Phone Number
Incident Details
* indicates a required field.
Workers' Compensation Claim
Employer Details
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
*Please enter a valid Phone Number
Worker's Compensation Insurance Details
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
*Please enter a valid Phone Number
Motor Vehicle Accident Details
Responsible Person’s insurance details
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
*Please enter a valid Phone Number
Insurance Information for Vehicle the Patient was in
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
*Please enter a valid Phone Number
Injured Family Members
Click here to add other family members injured in this accident that are covered under your health plan.Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
*Please enter a valid date.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
*Please enter a valid date.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
*Please enter a valid date.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Other Accident Type - Injury Details
If "Product Liability", please provide the name of the product.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
If Other, please describe the type of accident
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
*Please enter a valid Phone Number
If you are not making a claim or taking legal action because of this Injury / Illness please continue to the next step.
Signature & Verification
* indicates a required field.
*Please accept the acknowledgement
*Please enter a valid Signature
Special characters like | & ; $ % @ < > ( ) ! + are not allowed.
Contact Information and Confirmation email
What is the best number to reach you if we need to contact you?*Please enter a valid Phone Number
Please enter complete email address in the form: yourname@yourdomain.com.
*Please complete all required fields and fix all errors before proceeding to the next page.
The reference number or patient's last name entered was not found, please try again.
Tip: Please enter the information as it appears on the questionnaire. If you continue to experience problems, please contact us at the number listed on your questionnaire.
An online response has already been submitted for this reference number. If you have additional information please contract customer service at 800-645-9785.
Thank You! Your subrogation questionnaire information has been successfully submitted to Carelon Subrogation.