Group Health Cooperative / Group Health Options, Inc.
Incident Questionnaire
PO Box 210
5615 West Sunset Highway
Spokane, WA 99210-0210
Toll-free: 1-866-783-9594 or FAX: 509-241-7003
Our records indicate that services received by the patient named below appear to be related to an accident or injury. We have not declined any
benefits at this time, but Group Health is obligated to begin withholding benefits if this information is not received.
Please complete all sections of the form that apply to this accident or injury.
Name of injured:
Type of injury:
Address:
Group Health Member #:
Today’s date :
City, State, Zip:
*000103* MBRLTR2.LTR
1. General information
Date of incident:
Time of incident:
am / pm Location of incident:
Injuries you received: (If not related to a specific incident, please describe what caused the onset of symptoms, sign and return this form in the
enclosed envelope.)
Briefly describe the incident:
2. Complete this section for vehicle accident
Was the vehicle involved a:
Car?
Motorcycle?
Other?
Was the patient a:
Driver?
Passenger?
Pedestrian?
Were any other members of your family injured in this accident?
Name:
Member #:
Injuries:
Name:
Member #:
Injuries:
Vehicle #1
Vehicle #2
Registered Owner:
Registered Owner:
Telephone #: (Hm)
(Wk)
Telephone #: (Hm)
(Wk)
Auto Ins. Co.:
Auto Ins. Co.:
Telephone #:
Telephone #:
Adjuster:
Adjuster:
Claim or Policy #:
Claim or Policy #:
Which vehicle was at fault?
Vehicle #1
Vehicle #2
Which vehicle was the GROUP HEALTH enrollee riding in?
Vehicle #1
Vehicle #2
Revised 09/30/2009
3. Complete this section for on the job injury or illness
Did this condition or injury occur on the job or as the result of employment?
YES NO
If no claim was filed, please explain why:
If yes, did you apply for Worker’s Compe