Excess and or Subrogation Statement of Facts: Fill out & sign online

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Click ‘Get Form’ to open the Excess and/or Subrogation Statement of Facts in the editor.
Begin by entering your Participant Name and Certificate number, which can be found on your I.D. card. Next, fill in the Date of Incident and Time (A.M. or P.M.) along with the Exact Location of the Incident.
In section 1, describe the type of accident and any injuries experienced. Indicate whether the accident was reported to the police; if yes, provide details such as Police Officer Name, Police Report Number, and Police Station address.
For section 3, if known, enter information about the person responsible for your injuries including their name, contact details, insurance company information, and claim number.
If you have an attorney, complete section 4 with their name, contact information, and address.
In section 5, check one option regarding your intention to make a claim or lawsuit against responsible parties. Finally, certify that all provided information is true by signing and dating the form.

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