General Accident Questionnaire
Page 1 of 1
Name of Insured: Person Injured:
Insured ID: Certificate Number:
Date of Accident: ___/___/___ (MM/ DD/YYYY)
Please complete the questionnaire below and return to IMG so that we can update our records. Processing may be delayed
without this information.
1. Please provide exact details of the accident, including date, time, place and how it occurred. Please provide the address where the injury happened along with
the property owners name, name of the property/casualty insurance company insuring the property and its complete address and telephone number along
with the policy number.
2. Was this accident related to your employment? If so, please provide employer’s complete name and address.
3. Was a police report filed? If so, please provide a copy of this report.
4. If this injury was the result of a motor vehicle accident, please provide the name, address and telephone number of the auto insurance carrier handling this
5. Was this accident related to an organized or sanctioned athletic activity, involving regular or scheduled games and/or practices? If so, was an accident report
filed with the sports coordinator? Please provide a copy of any related accident reports.
6. In the event you have hired legal counsel, please provide IMG with the complete name, address and telephone number of the attorney.
General Accident
Version 0719IN01200796A190731
Signature of Insured: X___________________________________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
Version 0719
If needed you can overnight packages to following address:
2960 North Meridian Street, Indianapolis, IN 46208
Please print legibly and complete ALL SECTIONS of this form. Mail, fax, or email completed form to:
Address: International Medical Group, Inc. Claims, P.O. Box 9162, Farmington Hills, MI 48333-9162 USA,
Call: +1.800.628.4664 or outside U.S. +1.317.655.4500; Fax: +1.317.655.4505