Incident Report Form

You have received a request from us for additional information that we need in order to process your medical claims. If we do not receive this information within 45 days of our request, we will have to deny all claims relating to the accident or injury and you will be responsible for the charges. When completing this form, you will need to include the claim number for the claim that is currently pending for this information. This can be found on the form or claims processing report we mailed to you. In most cases we will be able to continue processing your claim from the information you submit, however please be aware that occasionally we may need to contact you for additional information.

Please complete all appropriate fields on the form regarding your illness or injury.

All fields marked with an asterisk - * - are required fields. You'll need to enter information in that field before you can go forward.

At the end of each section, there will be a "Next" link. Please click that link to show the next set of information that is required based on the information you entered. Keep going until you reach the bottom of the form, which is indicated with a "Submit" button.

Use of the Back button on your web browser will bring you back to this instruction page.

Click on the Next link below to begin...

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