Subrogation Identification and Referral Worksheet

Identifies third-party liability and recovery opportunities on a claim and routes them to the subrogation unit with the evidence needed to pursue recovery.

Referral Overview

• Why are you referring this claim?
• Claim Number
• Date of Loss
• Referral Date
• Line of Business

Third-Party Liability Indicators

• Primary liability basis
• Is a responsible third party known?
• Third-Party Name
• Third-Party Role
• Liability Summary

Evidence and Recovery Support

• Available evidence
• Upload supporting evidence
  Upload documents, photos, or reports that support the referral.
• Estimated Recovery Amount
  Best estimate of the amount that may be recoverable.
• Recovery Confidence

Referral Routing and Contact

• Your Name
• Your Department
• Your Work Email
• Your Work Phone
• Referral Priority
• Additional Notes

Consent and Submission

• I understand this form may collect claim-related PII and supporting documents needed for subrogation review.
• I confirm the information provided is accurate to the best of my knowledge.