After Hours Mayday Number For Trucking Clients Only
(800) 404-2908

Healthcare Liability Assignment Form

Please complete and submit the following information regarding your healthcare liability assignment

Your assignment will be forwarded to our nearest branch office for processing.

Please contact us with any questions or comments.

NOTE: Fields marked with an asterisk (*) are required.

Insured Information
Facility:*
Contact First Name:*
Contact Last Name:*
Contact E-Mail:*
Facility Address:*
Facility Address (cont):
City:*
State/Province:*
Zip Code:*
Phone Number:*
Resident/Visitor Information
First Name:*
Last Name:*
Gender:
Address:
Address (cont):
City:
State/Province:
Zip/Postal Code:
Medicare/Medicaid/Self-Pay:

Incident Information
Date of Incident/
Records Request/
Lawsuit:*

(MM/DD/YYYY)
Incident Location:
Shift:
Injury:
Body Part Injured (Please Be Specific):
Treatment:
How Incident Occurred:
 
Upload Supporting Documents
(DOC or PDF only please):

 
Upon submission, you will receive an email confirmation for your records.
 

* I acknowledge the form is completed.