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Accident Questionnaire/Other Insurance

Patient Name:

Date of Birth:

_________________________________

_____________________

Address:

______________________________________________________________________

1) Are you receiving Black Lung Benefits?

YES

NO

2) Are you receiving Worker’s Compensation benefits? YES NO

If yes, Date of accident:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3) Are you receiving treatment for an injury or illness which another party could be held

liable or could be covered under no-fault or auto insurance?

YES

NO

If yes, Date of accident:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

4) Will this claim be filed with any other insurance such as homeowners or business

liability, etc? YES

NO

If you answered yes to any of the above questions please complete the following:

N a m e o f i n s u r a n c e C o m p a n y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Address:

______________________________________________________________________

Insured:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

P o l i c y # : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Group#:

______________________________

Do you have any other insurance other than what you have listed above that you would like

to be filed on this claim?

___yes

___

no

If yes, please list information below.

Name of insurance company:______________________________________________________ Address: ______________________________________________________________________ Insured: ______________________________________________________________________ Policy#: __________________________________ Group#: ____________________________

Preferred hospital for your insurance company: ____________________________________

Preferred laboratory for your insurance company: __________________________________

___________________________________ Patient Signature

_____________________________ Date

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