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Answer Questionnaire

Bold labels and This graphic indicates a required field. indicate required information.

Enter your information:

Last Name:

Company:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Country:

Daytime Phone:
(include area code)

Date of Injury:
(mm/dd/yyyy)

Was the above service related to an incident that occurred:
On the Job
Auto
Motorcycle
Caused by another party
Other
No Accident
If No Accident, click submit form, otherwise, complete the appropriate sections below and then click submit.

If Work Related:

Name of Patient's Employer:

Address of Patient's Employer:

Is Patient Self-Employed?
Yes
No

Was the Workers' Compensation Claim declined?
Yes
No

Name of Workers' Compensation Center:

Address of Workers' Compensation Center:

Has patient filed a Workers' Compensation Claim?
Yes
No

If claim was denied, is patient appealing the decision?
Yes
No

If Auto/Motorcycle Related:

Name of Patient's Auto Insurance Carrier:

Address of patient's Auto Insurance Carrier:

Policy/Claim Number

Medical Benefits Limit:

Medical Benefits Limit met?
Yes
No

Uninsured Motorist Limit:

Uninsured Motorist Limit met?
Yes
No

Underinsured Motorist Limit:

Underinsured Motorist Limit met?
Yes
No

If Injury Caused by Another Party:

Name, Address, and Phone Number of Other Party:

Name Address, and Phone Number of Other Party's Insurance:

Name Address, and Phone Number of Your Attorney:

A leading provider of health care subrogation administration 888-540-4816 What Is Subrogation?
What is Your Subrogation Question?

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Contact Information
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The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

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Office Information

Laffey & Associates
415 Chartiers Avenue
Carnegie, PA 15106
Phone: 412-489-0328
Toll Free: 888-540-4816
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Subrogation Update download

At Laffey & Associates, our attorneys although located outside Pittsburgh Pennsylvania, serve employers and insurance companies Nationwide in subrogation litigation.