Blue Cross Blue Shield of Michigan

Subrogation Questionnaire

* Required field

* Today's date

* E-mail address

* Patient/Client name

* Date of birth

* Contract number (9-digit number on BCBSM card)

Spouse (if on BCBSM policy)

* Your phone number

BCBSM policy holder's name (if different from the client's name)

* Type of case (select one)

Personal injury

Product liability

Medical malpractice

Workers' compensation

Motor vehicle accident

Motorcycle accident

Other

Court or workers' compensation bureau,
if known

* Date of injury

* Type of injury/area of body injured

Notes

Attorney name (if you have hired one)

* Insurance company name

* Insurance adjuster name

* Insurance claim number

* Insurance street address

* Insurance city

* Insurance state

* Insurance ZIP code

* Insurance adjuster phone number

Insurance adjuster fax number

* Date and type of next scheduled hearing case

* Required field

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