Fillable Investigation Report Stephen M. Hillis, Manager Kentucky Assigned (Kentucky Insurance Plans)

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Investigation Report Stephen M. Hillis, Manager Kentucky Assigned (Kentucky Insurance Plans)

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Investigation Report
Stephen M. Hillis, Manager
Email Address:KyAuto@KAIP.org
www.kyinsplans.org
Claimant Name:
Assigned Control #:
Claim #:
Please provide the following information as it pertains to the above noted claim:
1- Claimant
Details
SSN (Last 4 Digits):
Accident Time:
Host Vehicle Driver:
DOB:
Address:
Nature & Extent of Injury:
Medical Treatment:
Employment and Wages:
Dependents:
2- Accident Details
Accident Date:
Accident Location:
Host Vehicle Owner:
Other Vehicle’s Insurance:
Accident Description:
Police Version (if applicable):
Witness Version (if applicable):
Kentucky
Assigned Claims Plan
PO Box 436509, Louisville, KY 40243
502-327-7105
Date:
Adjuster Name:
Company Name:
1 of 2
Investigation Report - Version 1.2020
SELECT
Pursuing Claimant Insurer
Pursuing Uninsured Owner
Subrogation Attorney Involved
Suit Filed to Protect Subrogation
Subrogation Remarks/Recommendations:
What Remains to Be Done to Resolve Claim:
Outstanding Reserves:
Out-of-State Insurance on Host Vehicle?
Private Health Insurance?
3- Eligibility Determination
Other Sources Available:
KY Insurance on Host Vehicle?
Insurance in Household?
Other Sources Impact on Eligibility:
Owner of Host Vehicle’s Name(s):
Eligibility Comments/Determination:
4- Claim Disposition
Amounts Paid:
Subrogation Open for the Following:
2 of 2
Investigation Report - Version 1.2020
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Investigation Report Stephen M. Hillis, Manager Kentucky Assigned (Kentucky Insurance Plans)

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Completed 11 July 2021

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