BeniComp Subrogation Questionnaire

Please complete the subrogation form below in order for BeniComp to pay the claim. The form below will help us determine if another insurance provider should pay, or has already paid for the claim.

Member Name Member Name First Last
Member DOB Member DOB / MM / DD YYYY
Member Phone Number Member Phone Number - ### - ### ####
Employer Name
Incident Details
Date of Accident Date of Accident / MM / DD YYYY
Description of Accident Location

Ex: at home, at sports stadium, at the mall, at grocery store, at girlfriend's house, on the street, etc.
Location Address of Accident Location Address of Accident
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Type of Case/Accident
Accident Details and Notes

BeniComp Subrogation Questionnaire

BeniComp Subrogation Questionnaire

Incident Details