Accident Information Questionnaire Optum
Accident Information Questionnaire

Welcome to We are investigating to determine if any other party or insurance carrier may have responsibility to pay for the medical treatment noted on the letter directing you to this website. The information we are requesting relates only to the incident referred to in that letter.

We respect your right to privacy and will handle the information you submit with utmost discretion.

Please enter your Case # that is listed on the letter you received. You will also need to enter the Case # a second time in order to confirm the number.

(* denotes a required field)
Case #               *
Confirm Case # *