BWC Subrogation Referral Form

BWC Subrogation Referral Form Claimant ________________ Claim No.________________ Claimant's PI Attorney and Address ________________________ ________________________ ________________________ Telephone No.____________ Third Party's Insurance Company Address, Claim No. and Claims Rep ________________________ ________________________ ________________________ Description of Accident ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Refer to: Date of Injury________________ Third Party Name and Address ____________________________ ____________________________ ____________________________ Telephone No.________________ Third Party's Attorney (If known) Name and Address ____________________________ ____________________________ ____________________________ Subrogation Department P.O. Box 15487 Columbus, OH 43215 Phone: (614) 466-6600 Fax: (614) 621-2549 Attached: MVA Report__ Other__ Specify____________ Referred By:__________________ Telephone:___________________ Affiliation:____________________ Date:________________________ American LegalNet, Inc. www.FormsWorkFlow.com