Insurance Documentation Form

Filling out the form below will provide us with all the medical insurance information we need in order to proceed with the investigation of this case.

Your Information

Who you are, what case this involves

My First Name *

My Last Name *

Case *

Name of the injured person

Case ID

Insurance Documentation

Which of the following does/did the injured person have? *

Medicare

Medicaid

Supplemental Insurance (e.g., Anthem, AARP, Aetna, etc.)

Medicare

Who has a copy of the injured person's Medicare card? *

If someone else, provide their name, contact information and relationship to the injured person:

Enter Medicare ID Number

If you know their Medicare ID Number, enter it above.

Upload Medicare Card

Maximum file size: 268.44MB

If you have a copy of their Medicare card, upload it above.

Medicaid

Who has a copy of the injured person's Medicaid card? *

If someone else, provide their name, contact information and relationship to the injured person:

Enter Medicaid Policy Number

If you know their Medicaid Policy Number, enter it above.

Medicaid Card

Maximum file size: 268.44MB

If you a copy of the Medicaid card, upload it above.

Supplemental Insurance

Who has a copy of the injured person's supplemental insurance card? *

If someone else, provide their name, contact information and relationship to the injured person:

What is the name of the supplemental insurance company? *

Supplemental insurance companies include AARP, Aetna, Blue Cross, etc.

Enter Supplemental Insurance Policy Number

Supplemental Insurance

Maximum file size: 268.44MB

If you have a copy of their supplemental insurance card, upload it above.

If you are human, leave this field blank.