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Excess and or Subrogation Statement of Facts

Excess and or Subrogation Statement of Facts 2026

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The document is an Excess and/or Subrogation Statement of Facts, which collects information from a participant regarding an accident, including details about the incident, injuries sustained, responsible parties, and any legal representation. It outlines the participant's intentions regarding claims against other parties and includes a Subrogation Agreement that requires reimbursement to the insurance plan for any payments made related to the injury if recovery is obtained from a third party.

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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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2019	4.8 Satisfied (35 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Do you have to respond to a subrogation letter?

For example, in any instance, you may have to file a claim with Medicare for your injuries, and Medicare sends you a subrogation letter. You have 30 days to respond. Your insurance company may have specific information within the letter to guide you in learning what steps you can (and must) take.

Why did I receive a subrogation letter?

It is a way for them to claim their share of compensation from whoever caused your accident. You are still compensated for your total damages, but because you received some money upfront from your insurer, they will want to get paid back through the settlement. The letter is their formal claim for that money.

How do you get notified about a subrogation claim made against you?

You will most likely get a notice letter. In the event that your insurer recovers money on the subrogation case, they would be required to give you a refund for any deductible you had to pay on your claim. There will be some difference from state-to-state but the law is largely similar in most states.

What is a subrogation statement?

Subrogation allows your insurer to recoup costs (medical payments, repairs, etc.), including your deductible, from the at-fault drivers insurance company, if the accident wasnt your fault. A successful subrogation means a refund for you and your insurer.

Why is my insurance sending me a subrogation letter?

Subrogation occurs when an insurance company seeks reimbursement from a third party after paying a claim. If you owe money related to a claim, communicate promptly with the subrogation department. Review all documents carefully, keep records of correspondence, and understand your policy terms.

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