ICC Insured Questionnaire
Welcome to the Optum on-line injury questionnaire. We are investigating to determine if any other party or insurance carrier may have responsibility to pay for the medical treatment noted on the letter directing you to this website. The information we are requesting relates only to the incident referred to in that letter. We respect your right to privacy and will handle the information you submit with utmost discretion.
* Required fields
Optum File Number:
Policy Holder's Full Name:*
Patient's First Name:*
Patient's Last Name:*
Patient's Street Address:*
City:*
State:*
Select..
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:*
Home Phone Number:*
(Ex:(999) 999-9999)
Work Phone Number:
(Ex:(999) 999-9999)
Were the charges indicated related to an accident/injury?*
Select..
Yes
No
Select the primary cause for the patient to visit the doctor*
Home
Motorized Vehicle
Animal Related
Work Related
Sports
Assault
Business Property
Other Property
Other
When did the accident/injury occur?:*
Please describe in detail how the injury occurred*
Where did the injury or accident occur?
Was a police report made?
Select..
Yes
No
Name of the Police Department called?
If you have a police report, please provide us with a copy.
You can either Mail, or Fax us a copy.
Fax: 920-662-8340
Mail
P.O. Box 13216
Green Bay, WI 54307-3216
Have you obtained or considered obtaining an attorney?*
Select..
Yes
No
Law Firm's Name
Attorney's Name
Attorney's Address
Attorney's Phone Number
Have you received a settlement?
Select..
Yes
No
Date Settled
With whom did you settle?
Please describe the reason for treatment*
When did the condition begin?
We'll need the following information from the patients motorized vehicle or auto insurance
Company Name
Phone Number
Policy Number
Claim Number
Policy Holder's Name
We'll also need the following information from the other party that is involved in the accident
Other Party's Name
Other Party's Address
Other Party's Phone Number
Auto Insurance Company's Name
Auto Insurance Phone Number
Auto Insurance Policy Number
Auto Insurance Claim Number
We'll need the following information from the animal owner
Name
Address
Phone Number
Animal Owner Insurance Company
Animal Owner Insurance Policy Number
We'll need the following information about the work incident
Patient's employer
Patient's employer's address
Has the patient notified their employer?
Select..
Yes
No
Has the employer filed a claim with Worker's Compensation?
Select..
Yes
No
Worker's Compensation Company Name
Worker's Compensation Address
Worker's Compensation Policy Number
Worker's Compensation Claim Number
Has the Worker's Compensation denied your claim
Select..
Yes
No
If your Worker's Compensation claim has been denied, please provide us with a copy of the denial.
You can either Mail, or Fax us a copy.
Fax: 920-662-8340
Mail
P.O. Box 13216
Green Bay, WI 54307-3216
We'll need the following information about the assailant
Name
Address
Phone Number
We'll need the following information about the business
Name of business
Address
Phone Number
Property Insurance Company
Property Insurance Policy Number
We'll need the following information about the property owner
Name
Address
Phone Number
Property or Homeowners Insurance Company
Property or Homeowners Insurance Policy Number
Additional Comments:
I accept the details provided are true as per my knowledge.
