Subrogation Form

* = required

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*
(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)
  • Auto accident
  • Motorcycle accident
  • Fall
  • Injury at home
  • Injury at work
  • Personal injury
  • Other
  • None of the above

Section 3: Accident and claim information

Was anyone at fault?
Did you file a claim against the liable party?

 (Please email a copy of any claim-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

Type the above number: