Claim Questionnaire

We are not a collection agency, and patients may hear from us before receiving a bill or statement from the healthcare provider.

Please take a moment and fill out our Claim Questionnaire below or call us directly at 833-760-0817.

Owner's Name
Owner's Auto Insurance Co.
Owner's Policy Number
Have you filed a claim with the Owner's Auto Insurance Company? If YES, answer the below questions.
YESNO
Claim Number:
Adjuster's Name:
Adjuster's Phone

Responsible Party's Name
Responsible Party's Insurance Company
Responsible Party's Policy Number
Have you filed a claim with the Responsible Party's Insurance Company? If YES, answer the questions below.
YESNO
Claim Number:
Adjuster's Name:
Adjuster's Phone:
Were you injured by a product or while using equipment? If YES, answer the questions below.
YESNO
Manufacturer:
Model/Type of Product:
Were you injured while at work? If YES, answer the below questions.
YESNO
Employer's Name:
Employer's Phone:
Workers' Compensation Carrier:
Claim Number:

YESNO
Attorney's Name:
Attorney's Phone:
Signature of Patient (or Legal Guardian)
Date
Home Phone:
Work Phone:
Email
I agree that I have correctly completed this questionnaire to the best of my ability and I authorize its use by Cognizant.
I Acknowledge and Agree