Subrogation Form Sample PDF Details

In managing the complexities of insurance claims, especially those involving injuries and third-party responsibilities, the subrogation process plays a crucial role in ensuring that the correct parties are held accountable for financial liabilities. The Subrogation Sample form, provided by Gilsbar, a company focused on enhancing business operations and improving lives, offers a structured method for individuals to report incidents that may involve subrogation—when an insurance company seeks reimbursement from the responsible party after paying out benefits to the insured. This form captures essential details across multiple sections, including personal information, incident specifics, automobile insurance data, other insurance details, and even attorney information, if applicable. Additionally, the form contains a significant acknowledgment regarding the agreement to reimburse the medical plan for benefits paid out, due to any settlements received related to the injury. The thoroughness of this document ensures all relevant data is collected to assist Gilsbar and The Phia Group, the administrator responsible for pursuing these subrogation and reimbursement claims, in effectively managing and processing these complex cases. By understanding and accurately completing this form, individuals play a critical role in the transparent and fair resolution of claims, paving the way for equitable reimbursement practices within the insurance industry.

QuestionAnswer
Form NameSubrogation Form
Form Length2 pages
Fillable?Yes
Fillable fields58
Avg. time to fill out12 min 10 sec
Other names3rd, Subrogation, subrogation form sample, workers compensation waiver

Form Preview Example

Gilsbar

Enhancing Business. Improving Lives.

SUBROGATION FORM

Employer or Group Name: ________________________________________ Group Number: _____________

Employee Name: ___________________________________________________________________________

Soc. Sec. # or Member ID # _________________________________________________________________

Dependent Name: __________________________________________________________________________

Section A - Incident Information (if checked, all felds are required).

 

Please describe the incident below:

 

 

 

Date of incident: __________________________________________________________________

 

Type of incident: __________________________________________________________________

 

Type of injuries sustained: __________________________________________________________

 

__________________________________________________________

 

Are you still being treated?

Yes

No

 

Did you fle a claim (other than Gilsbar)?

Yes

No

 

If yes, with whom? ___________________________________________________________

 

Incident details and location ___________________________________________________

 

(Street, City, State, etc.) ______________________________________________________

 

______________________________________________________

Section B - Motor Vehicle Accident (if checked, all felds are required).

 

Type: Single Vehicle

Multiple Vehicle

 

 

Names of other family members injured in accident: _____________________________________

 

_____________________________________________________

 

Police report fled?

Yes

No

 

Did the other driver admit fault?

Yes

No

 

Who, if anyone, was cited? __________________________________________________________

 

Did you give a statement?

Yes

No

 

Was a settlement reached?

Yes

No

 

Has a release been signed?

Yes

No

Section C - Your Automobile Insurance Information (if checked, all felds are required).

Driver Name: _____________________________________________________________________

Owner Address: ___________________________________________________________________

____________________________________________________________________

Owner Phone: ___________________________________________

Insurance Company: _______________________________________________________________

Insurance Company Address: _______________________________________________________

_______________________________________________________

Adjuster Name: ___________________________________________________________________

Adjuster Phone Number: ___________________________________

Policy #: ________________________________________________

Claim #: ________________________________________________

Section D - Other Insurance Information (if checked, all felds are required).

The responsible party’s automobile insurance, the worker’s compensation insurance, or homeowner’s/liability insurance:

Name: __________________________________________________________________________

Address: _________________________________________________________________________

____________________________________________________________________

Phone: _______________________________________________

Insurance Company: _______________________________________________________________

Insurance Company Address: _______________________________________________________

_______________________________________________________

Adjuster Name: ___________________________________________________________________

Adjuster Phone Number: ___________________________________

Policy #: ________________________________________________

Claim #: ________________________________________________

Section E - Attorney Information (if checked, all felds are required).

Attorney Name: ___________________________________________________________________

Firm Name: ______________________________________________________________________

Firm Address: ____________________________________________________________________

____________________________________________________________________

Attorney Phone Number: _______________________________________________

Attorney Fax Number: _________________________________________________

I hereby acknowledge that my medical plan has a subrogation/reimbursement agreement provision which provides that medical benefts paid under the plan on behalf of me or any person covered under my plan. I agree to reimburse (up to the amount of such benefts paid) from any payments, awards, or settlements which may be paid by a third party because of the injury described above. I authorize Gilsbar, LLC and the Phia Group to release information regarding any claims in order to directly seek and receive such reimbursement from any third party payments that may in the future, become payable because of this injury. Furthermore, I hereby authorize any medical provider, my lawyer or agent, or any other person or corporation to release any and all medical information relating to the incident to The Phia Group.

The Phia Group is the administrator who pursues subrogation and reimbursement claims on behalf of Gilsbar. Thank you for your cooperation.

I represent that, to the best of my knowledge, the information provided on this form is complete and accurate.

Signature: ____________________________________________________________________

Date: ______________________________________

How to Edit Subrogation Form Online for Free

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Step 1: Click on the "Get Form Here" button.

Step 2: At this point, it is possible to modify the subrogation form sample. The multifunctional toolbar helps you insert, delete, adapt, highlight, and also conduct other commands to the content and areas inside the document.

Provide the content requested by the program to prepare the document.

nc waiver of subrogation pdf empty fields to consider

Note the details in Type Single Vehicle Names of other, Police report fled Did the other, Yes Yes Yes, No No No, Yes Yes, No No, Section C Your Automobile, Driver Name Owner Address, and Owner Phone Insurance Company.

Filling in nc waiver of subrogation pdf stage 2

You may be requested for certain key particulars if you want to fill out the Owner Phone Insurance Company field.

nc waiver of subrogation pdf Owner Phone  Insurance Company blanks to insert

The Section D Other Insurance, The responsible partys automobile, Name Address, Phone Insurance Company, Section E Attorney Information if, and Attorney Name Firm Name Firm field is going to be place to insert the rights and responsibilities of all parties.

Filling out nc waiver of subrogation pdf step 4

Finish the file by reviewing the following sections: Attorney Name Firm Name Firm, Attorney Phone Number Attorney, I hereby acknowledge that my, The Phia Group is the, and I represent that to the best of my.

step 5 to completing nc waiver of subrogation pdf

Step 3: Press the Done button to save your file. At this point it is available for transfer to your electronic device.

Step 4: Try to get as many duplicates of your form as you can to avoid possible complications.

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