Subrogation Form Sample PDF Details

When an insurance policy is issued, the insured individual agrees to certain terms and conditions. One of these terms may be that the insurance company has the right to pursue subrogation in the event of a loss. This means that, if another party is responsible for damages covered by the policy, the insurance company has the right to seek reimbursement from that party. A subrogation form can be used to document this agreement and protect both the insurer and the insured in case of a dispute. Here we provide a subrogation form sample for your reference. Please note that this is only an example, and you should consult with an attorney before submitting any legal documents related to subrogation.

You can find details about the type of form you want to prepare in the table. It can show you how long it will need to complete subrogation form sample, what parts you need to fill in and several further specific facts.

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

Form Preview Example


Enhancing Business. Improving Lives.


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?




Did you fle a claim (other than Gilsbar)?




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?




Did the other driver admit fault?




Who, if anyone, was cited? __________________________________________________________


Did you give a statement?




Was a settlement reached?




Has a release been signed?



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

Our PDF editor allows you to fill out documents. You won't have to perform much to enhance of documents. Just simply stick to these actions.

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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