| Incident Number | Date of Loss | Insurance Company Name | Patient Name | CMS Claim Form |
|---|---|---|---|---|
| TX-HS-403-22-341-EE | 08/14/2022 | PROGRESSIVE INSURANCE – MEDICAL | JOANN SAENZ | CMS-for-Incident-934147458.pdf |
| TX-HS-403-22-341-E | 08/14/2022 | INFINITY COUNTY MUTUAL | CMS-for-Incident-142560575999001.pdf | |
| TX-CW-201-22-467573-E | 09/14/2022 | STATE FARM MUTUAL INSURANCE | CMS-for-Incident-536-6039-H07-43-002.pdf | |
| TX-AK-305-22-103-E | 06/24/2022 | ACUITY A MUTUAL INSURANCE | WAYNE WALGER | CMS-for-Incident-ZC7442.pdf |
| TX-CW-201-2021-436129-E | 08/10/2021 | BURKHART INSURANCE | SELENE LOZANO | CMS-for-Incident-CPIN0560117357.pdf |
| TX-RN-424-22-1518-E | 02/02/2022 | PROGRESSIVE INSURANCE – MEDICAL | CMS-for-Incident-944782058.pdf | |
| TX-WZ-208-21-12115-E | 12/14/2021 | STATE FARM INSURANCE-MPC UNIT | CMS-for-Incident-332-8717-H02-43C-002.pdf | |
| OK-59-007-22-33-EE | 03/09/2022 | GREAT WEST CASUALTY | DAVID TILLY | CMS-for-Incident-GWP37571P.pdf |
| OK-59-007-22-33-E | 03/09/2022 | CHUBB NATIONAL INS. CO. | DAVID TILLY | CMS-for-Incident-.pdf |
| TX-XR-403-22-29-EE | 02/06/2022 | TEXAS FARM BUREAU | CAROLINE BLACKARD | CMS-for-Incident-21914614.pdf |
| TX-XR-403-22-29-E | 02/06/2022 | PROGRESSIVE INSURANCE – MEDICAL | CAROLINE BLACKARD | CMS-for-Incident-06090192-4.pdf |
| MO-05-307-22-414-E | 04/23/2022 | NATIONAL GENERAL INSURANCE | CMS-for-Incident-2014561697.pdf | |
| TX-RN-424-22-1518-E | 02/02/2022 | PROGRESSIVE INSURANCE – MEDICAL | CMS-for-Incident-944782058.pdf | |
| TX-WB-206-2021-43-E1 | 01/13/2021 | GEICO INSURANCE – MEDICAL | PAYDNE DOWNING | CMS-for-Incident-6046517428.pdf |
| TX-SH-201-C22-06854-E | 03/29/2022 | HUDSON INSURANCE | RAFAEL SEGOVIA | CMS-for-Incident-HMU200095-05.pdf |
| TX-AC-309-22-34-E | 03/02/2022 | OLD AMERICAN COUNTY MUTUAL | CMS-for-Incident-TEJ01904926-00.pdf | |
| TX-HS-403-2021-430-E | 09/30/2021 | METROPOLITAN CASUALTY – MEDICAL | CMS-for-Incident-A7999825100.pdf | |
| TX-HS-403-2021-430-EE | 09/30/2021 | ENCOMPASS – PIP / MEDPAY | SUSIE GUNN | CMS-for-Incident-282570728.pdf |
| TX-HS-403-2021-437-E | 10/02/2021 | USAA INSURANCE – MEDICAL CLAIMS | CMS-for-Incident-014553130U-71067.pdf | |
| TX-KB-403-22-0339-E | 01/05/2022 | ZURICH NORTH AMERICA | RICKY SPARKS | CMS-for-Incident-BAP2347204.pdf |
| Incident Number | Date of Loss | Insurance Company Name | Patient Name | CMS Claim Form |