Wisconsin Casualty

Subrogation Recovery Information Form

Recipient / Member (Injured Party) Information

First Name:

Last Name:

Date of Birth:

(MM/DD/YYYY)

Address:

City:

State:

Zip Code:

Phone Number:

Social Security No:

Member ID:

Accident / Incident and Injury Information

Accident/Incident Date: (MM/DD/YYYY)

Accident/Incident Type:

Please describe the accident and injuries:

Please Select the Injury Type(s):

Fracture

Dislocation

Internal Injury

Intracranial

Sprain and/or Strain

Burn

Poisoning

Open Wound Lower Limb

Trauma Complications

Late Effect of Injuries

Crushing Injury

Contusion

Open Wound Head/Neck/Trunk

Foreign Object in Body

Superficial Injury

Nerve Damage

Blood Vessel

Open Wound Upper Limb

Toxic Effect of Substance

Other/Unknown

Please Select Body Part(s) Injured:

Skull/Face

Neck/Throat

Shoulder

Spine

Thorax/Chest

Upper Arm

Elbow

Lower Arm

Hands

Hip

Upper Leg

Knee

Lower Leg

Foot

Liable Person(s) Involved Information

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Liable Insurance Company Information

Insurance Co Name:

Adjuster First Name:

Adjuster Last Name:

Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Policy No:

Claim No:

Plaintiff Attorney Information

First Name:

Last Name:

Law Firm Name:

Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Email Address:

Defense Attorney Information

First Name:

Last Name:

Law Firm Name:

Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Email Address:

Information of Person Submitting This Form

First Name:

Last Name:

Company/Org Name:

Phone Number:

Email Address:

If you are a Medical Provider, please enter your Provider Number:

Attach Documentation

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