One Claim – Midland One Claim

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(855) 859-0058 oneclaim@midlandgroup.com

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Accident-Related Hospital bills

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Company
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My Profile
Please tell us about how yourself and how you can be contacted.
Patient Name*
First Last
Patient Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Patient Phone*
Patient Email*

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My Injury
Please tell us about how and where you were injured.
Date of Injury*
MM slash DD slash YYYY
How did your injury occur?*
- On the Job
- Motor Vehicle Accident
- At Home
Did you go to the hospital?*
- Yes
- No
Date of Visit*
MM slash DD slash YYYY
Name of Hospital*

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Do you have health insurance?*
- Yes
- No
Health Insurance
Tell Us About Your Health Insurance
Health Insurance Name*
Subscriber Name*
Subscriber ID*
Group Name or Number*
Phone Number*

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Legal Representation
Do you have legal representation?*
- Yes
- No
Law Firm or Attorney
Tell Us About Your Law Firm or Attorney
Attorney Name*
Law Firm Name*
Phone Number*
Law Firm Address*
Address City State ZIP

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Motor Vehicle Accident
Tell Us About Your Motor Vehicle Accident
Did the accident involve more than one vehicle?*
- Yes
- No
Was someone else found at-fault for the accident?*
- Yes
- No
What was your role in the accident?*
- Driver
- Passenger
- Other
Date of Accident*
DD slash MM slash YYYY
Location or Address of Accident*

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Motor Vehicle Insurance - Person Responsible
Did the person responsible for the accident have insurance?*
- Yes
- No
Insurance Policy (Person Responsible)
Tell Us About The Motor Vehicle Insurance FOR THE PERSON RESPONSIBLE FOR THE ACCIDENT.
Auto Insurance Carrier*
Insured / Policy Holder Name*
Policy Number*
Claim Number
Adjuster Name
Adjuster Phone Number

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Motor Vehicle In Accident
Tell Us About The Motor Vehicle Insurance FOR THE VEHICLE YOU WERE IN during the accident.
Auto Insurance Carrier*
Insured / Policy Holder Name*
Policy Number*
Claim Number
Adjuster Name
Adjuster Phone Number

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Your Motor Vehicle Insurance Policy
Tell Us About YOUR Motor Vehicle Insurance (even if your vehicle was NOT involved in the accident).
Auto Insurance Carrier*
Insured / Policy Holder Name*
Policy Number*
Claim Number
Adjuster Name
Adjuster Phone Number

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Your Employer
Tell Us About Your Employer
Employer Name*
Contact Name*
Phone Number*
Employer Address*
Address City State ZIP

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Your Employer's Insurance
Tell Us About Your Employer's Workers' Compensation Insurance Carrier.
Workers' Comp Insurance Carrier*
Insured / Policy Holder's Name*
Policy Number*
Claim Number*
Adjuster's Name*
Phone Number*

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General Accident
Please describe your accident.
Where did the accident occur?*
Business Name or Person Owning the Property*
Property Address*
Address City State ZIP
Insurance Carrier, if known*
Phone Number*

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Agreement
I agree that the statements and answers I have made on this claim form are accurate as of the date I made them and I have NOT made any attempt to mislead nor misrepresent my claim.
Please Indicate Your Agreement with the Statement.*
- I Agree
Signature*

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