Accident - Incident Questionnaire

Dear Member,

Core Management Resources Group has received an accident-related claim for treatment or a medical condition that may apply to your health insurance coverage.

To ensure your claim is processed correctly, please complete and submit this Accident - Incident Questionnaire. The information you provide will assist in determining whether another party (such as an automobile insurance carrier or workers' compensation) may be responsible for payment of your medical expenses.

We cannot continue processing your claim until you have completed and submitted this questionnaire.

Next Steps

  1. Complete the General Information section of the questionnaire.
  2. Complete any additional sections that apply to your situation.
  3. Review your responses for accuracy.
  4. Electronically sign and submit the questionnaire.
  5. Contact Customer Service if you need assistance completing the questionnaire.

Need Assistance?

If you have questions about this questionnaire or need assistance completing it, please contact Core Management Resources Group Customer Service.

Phone
478-741-3521
888-741-2673

Hours of Operation
Monday – Friday
8:00 AM – 5:00 PM Eastern Time

Please complete all applicable sections of this questionnaire as accurately and thoroughly as possible. A determination will generally be made within 30 days after your completed Incident Questionnaire has been received. If additional information is needed, a representative may contact you.
THE INFORMATION BELOW IS REQUIRED TO PREVENT THE DENIAL OF YOUR CLAIM.

Thank you for your assistance and for allowing us to serve you.

Accident - Incident Questionnaire

The information below is required to prevent the denial of your claim.

General Information





Which methods of contact do you prefer? (Check all that apply) *

Contact Information






What caused the injury or illness? *




Attorney Information

Have you hired, or do you intend to hire, an attorney to assist you with this matter? *

Supporting Documentation

If you have obtained a police report related to this accident, you must submit a copy of the police report with this questionnaire. The police report is required when one has been obtained and should be uploaded in the Supporting Documentation section below. Failure to provide a police report that has been obtained may result in delays in processing your claim and could impact the determination of your claim.

You may also upload other documentation that may assist in the review of your claim, including medical records, workers' compensation or insurance documentation, photographs of the incident or injuries, and any other records relevant to your claim. Providing complete and accurate documentation may help prevent delays in the review and processing of your questionnaire.

Certification & Signature

I certify that the information provided on this questionnaire is true and complete to the best of my knowledge.