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Run: Subrogation Identification and Referral Worksheet

A subrogation referral worksheet for identifying third-party liability, attaching supporting evidence, and routing the claim to the subrogation unit. Use it ...

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Referral Overview

Why are you referring this claim? (required)

Claim Number (required)

Date of Loss (required)

Referral Date (required)

Line of Business (required)

Third-Party Liability Indicators

Primary liability basis (required)

Is a responsible third party known? (required)

Third-Party Name

Third-Party Role

Liability Summary (required)

Evidence and Recovery Support

Available evidence (required)

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 (required)

Referral Routing and Contact

Your Name (required)

Your Department (required)

Your Work Email (required)

Your Work Phone

Referral Priority (required)

Additional Notes

Consent and Submission

I understand this form may collect claim-related PII and supporting documents needed for subrogation review. (required)

Yes No N/A

I confirm the information provided is accurate to the best of my knowledge. (required)

Yes No N/A

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Email (required)

Your name (optional)

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