Subrogation Form

Section 1: Patient injury information

Where is my file number?

Your assigned file number is located at the bottom of the questionnaire we mailed you.

What if I don't have a file number?

If you don't have an assigned file number, don't fill out this form. Instead, you may choose to fill out a subrogation questionnaire (PDF) for a new case.

Section 2: Patient injury information

Has the patient recently been treated by a doctor for an accidental injury? (required)

(If "No," don't fill out the rest of the form, just click "Submit" to finish.)

Was the patient treated for injuries related to: (Check all that apply.)

Section 3: Accident and claim information

Please select your state.

Was anyone at fault?

Did you file a claim against the liable party?

 (If work related, please email a copy of related forms to

Section 4: Responsible insurance company (if not BCBSM)

Section 5: Your attorney information

Did you hire an attorney?

Section 6: Your information

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