Attorneys Refer Or Request A Case

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Please submit the information below to set up a case for Intellivo’s subrogation department. Please note: Intellivo does not process healthcare claims or bills.

Injured Party Information(Required)

First Name:

Last(Required)

Last Name:

Date(Required)

Date of Birth:

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Injured Party Information(Required)

First Name:

Last(Required)

Last Name:

Date(Required)

Date of Birth:

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Would you like to add Additional Involved Plan Members?

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Injured Party Information(Required)

First Name

Last(Required)

Last Name:

Date(Required)

Date of Birth:

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Would you like to add Additional Involved Plan Members?

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Injured Party Information(Required)

First Name

Last(Required)

Last Name:

Date(Required)

Date of Birth:

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Injured Party Information(Required)

First Name

Last(Required)

Last Name:

Date(Required)

Date of Birth:

Injury/Incident Details(Required)

Date of Initial Accident or Injury:

Description of Accident:(Required)

Description of Accident:

Type of Injuries Sustained:(Required)

Type of Injuries Sustained:

Health Insurance Information(Required)

Health Plan Provider: (e.g., Cigna, Aetna)

Health Insurance ID Number:

Name of Employer or Company Funding the Health Insurance Plan:(Required)

Name of Employer or Company Funding the Health Insurance Plan:

Health Insurance Card:

Max. file size: 100 MB.

Claim Contact Information(Required)

Claim Representative:

Law Firm’s Name:(Required)

Law Firm’s Name:

Attorney’s Name:(Required)

Attorney’s Name:

Paralegal or Case Manager’s Name:(Required)

Paralegal or Case Manager’s Name:

Insurance Company Name:(Required)

Insurance Company Name:

Claim Number:(Required)

Claim Number:

Coverage Type:(Required)

Coverage Type:

Claim Handler or Adjuster’s Name:(Required)

Claim Handler or Adjuster’s Name:

Phone(Required)

Phone Number:

Email Address:(Required)

Email Address:

Enter Email Confirm Email

Fax(Required)

Fax Number:

Has this Case Settled?(Required)

Has this Case Settled?

Yes

Additional Contact for Follow-up(Required)

Email Address:

Enter Email Confirm Email

Upload Additional Documents:

Max. file size: 100 MB.

Additional Comments

For questions regarding existing cases, please contact your case representative directly. Note: Intellivo cannot reprocess or approve healthcare claims for the TPA.

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Attorneys Refer Or Request A Case

Refer a new case or
request a new case to be opened

Simply brilliant solutions start with you

We are here to answer your questions

Never miss an update from Intellivo

Next Steps: Sync an Email Add-On

Attorneys Refer Or Request A Case

Refer a new case orrequest a new case to be opened

Simply brilliant solutions start with you

We are here to answer your questions

Never miss an update from Intellivo

Next Steps: Sync an Email Add-On

Refer a new case or
request a new case to be opened