Insurance Account Application

Insurance Company Name *

Bill To

Insurance Company's Billing Address *

Apt, suite, etc.

Country

City

State

Zip code

Billing Fax Number

Billing Email

Billing Contact Person or Adjuster *

Adjuster's Mobile Phone

Adjuster's Phone Number

Billing Contact Email Address

Billing Options *

Email Invoice

Fax Invoice

Fax and Email Invoice

Please fill out only if someone other then the adjuster listed above is filling out this form

PERSON SETTING UP ACCOUNT

COMPANY

ADDRESS:

Phone

Passenger's Details

Claim Number *

Passenger's Name *

Passenger's Home Phone *

Passenger's Mobile Phone

Passenger's Email

Passenger's Address *

Apt, suite, etc.

Country

City

Zip code

Account Ristrictions

Who will be booking the Trips?

Client

Insurance Company

Rehab or Physio Team

Case Manager or Lawyer

Are There Any Restrictions to Travel

Yes

IF RESTRICTED TO SPECIFIC ADDRESSES, PLEASE LIST:

Instructions

The undersigned acknowledges that they have the authority to open this account on behalf of the previously named insurance company

PRINT FULL NAME OF INSURANCE ADJUSTER *

SIGNATURE OF INSURANCE ADJUSTER

Reset Signature

Date