Insurance Subrogation Claim Form

INSURANCE SUBROGATION CLAIM FORM

Claim Identification

Claim File Number:   Insurer Name:

Insured Name:   Policy Number:

Applicant / Claimant Information

Date of Birth:   Telephone:

Policy Details

Policy Type:   Coverage Limit: $

Deductible: $   Premium: $

Policy Period From:   To:

Loss / Incident Details

Date of Loss:

Loss Valuation and Payments

Total Paid by Insurer: $   Subrogation Reserve Amount: $

Coverage & Recovery

Applicable Coverages (check all that apply):

Property Damage    Liability    Auto Physical Damage    Medical Payments    Other (describe below)

Documentation Checklist

Please indicate which documents accompany this claim:

Police Report   Photographs   Repair Estimate(s)   Medical Records/Bills

Invoices/Receipts   Witness Statements   Proof of Prior Payments   Other (describe below)

Third Party and Legal Status

Yes   No

Yes   No

Subrogation Rights and Assignment

By signing below, Claimant certifies that the insurer is entitled to subrogation and assignment of any rights of recovery against the third party responsible for the loss to the extent of payments made. Claimant agrees to cooperate fully with the insurer in any subrogation or recovery action, including but not limited to providing executed assignments, attending depositions, producing documents, and executing additional instruments reasonably necessary to perfect or enforce subrogation rights.

Claimant acknowledges that any recovery obtained from the responsible third party will be applied first to reimburse amounts paid by the insurer for the loss, reasonable subrogation costs and expenses, and any outstanding deductible or indemnity obligations as required by the policy or applicable law. Claimant further acknowledges that insurer may pursue recovery in Claimant's name and may withhold payment of any amounts otherwise due to Claimant pending resolution of subrogation rights.

Exclusions and Limitation of Liability

This subrogation claim does not alter coverage exclusions set forth in the underlying insurance policy. Insurer makes no admission of liability by accepting or processing this form. Submission of this form is without prejudice to any rights, defenses, or coverage positions available to the insurer under the policy, and nothing in this form shall be construed as a waiver of insurer's rights unless expressly stated in a separate signed writing.

Beneficiary / Payee Information

Relationship to Insured:   Recovery Percentage:

Certification and Authorization

I certify, under penalty of perjury and as an authorized representative of the claimant, that the statements made in this claim form are true and correct to the best of my knowledge and that I have not intentionally suppressed or withheld any material information. I authorize the insurer and its representatives to obtain, review, and use records and information relating to this claim and to pursue subrogation and recovery against any responsible third party. I further authorize third parties to release information to the insurer that is necessary to evaluate or prosecute this claim.

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