| Incident Number | Date of Loss | Insurance Company Name | Patient Name | CMS Claim Form |
|---|---|---|---|---|
| AL-01-712-23-65-E | 05/12/2023 | STATE FARM INSURANCE-MPC UNIT | LILLY ADAMS | CMS-for-Incident-5713429-B07-01.pdf |
| TX-CW-201-23-3054-E | 05/11/2023 | REDPOINT COUNTY MUTUAL INSURANCE CO. | ALICIA AGUILAR | CMS-for-Incident-BGS01012569.pdf |
| MO-05-307-22-165-E | 11/21/2022 | STATE FARM | MICHAEL INMAN | CMS-for-Incident-5746409-F26-25.pdf |
| TX-KP-401-22-141-EE | 08/17/2022 | STATE FARM INSURANCE-MPC UNIT | CMS-for-Incident-157-4084-F10-43J-001.pdf | |
| TX-KP-401-22-141-E | 08/17/2022 | TEXAS FARM BUREAU | SALLY MCCOMMON | CMS-for-Incident-23378237.pdf |
| TX-CN-310-23-44965-E | 03/16/2023 | IGNITION INSURANCE | CMS-for-Incident-GNM-40065352-0000.pdf | |
| TX-CN-310-23-44965-EE | 03/16/2023 | TEXAS POLITICAL SUBDIVISIONS JSIF | MARTIN HUERTA | CMS-for-Incident-22-F0647.pdf |
| TX-CX-409-23-9-E | 03/22/2023 | MID-CENTURY OF TEXAS | CMS-for-Incident-535681659.pdf | |
| OK-16-015-22-88 | 03/17/2022 | EQUITY INSURANCE COMPANY | CMS-for-Incident-N35296529.pdf | |
| TX-AK-305-23-323-E | 02/23/2023 | USAA INSURANCE – MEDICAL CLAIMS | CMS-for-Incident-053-221-145.pdf | |
| TX-KP-401-23-30-E | 02/03/2022 | HOME STATE COUNTY MUTUAL INSURANCE | SETH WHITMER | CMS-for-Incident-00102807.pdf |
| TX-SH-201-C23-02139-E | 01/24/2023 | GEICO INSURANCE – MEDICAL | CMS-for-Incident-0952138808.pdf | |
| TX-SH-201-C23-02139-EE | 01/24/2023 | GEICO INSURANCE – MEDICAL | JAZMIN LEDAY | CMS-for-Incident-0952138808.pdf |
| AL-01-403-23-91-E | 01/23/2023 | ALFA INSURANCE | STEPHEN KILEY | CMS-for-Incident-A2260471.pdf |
| AL-01-403-23-16-E | 01/05/2023 | ACE AMERICAN INSURANCE | LOYCE FULGHAM | CMS-for-Incident-ISAH2555932A.pdf |
| TX-CW-201-22-462446-E | 07/12/2022 | PROGRESSIVE COUNTY MUTUAL INSURANCE | CMS-for-Incident-950668177.pdf | |
| TX-CW-201-22-464039-EE | 07/30/2022 | STATE FARM COUNTY MUTUAL INS. TEXAS | SAMUEL RAMOS | CMS-for-Incident-485-8552-G15-43-001.pdf |
| TX-CW-201-22-464039-E | 07/30/2022 | STATE FARM COUNTY MUTUAL INS. TEXAS | CMS-for-Incident-485-8552-G15-43-001.pdf | |
| TX-CW-201-22-461825-E | 07/05/2022 | TEXAS FARM BUREAU | CMS-for-Incident-23242711.pdf | |
| TX-CW-201-23-476629-E | 01/12/2023 | STATE FARM MUTUAL INSURANCE | BRANDON MORRISON | CMS-for-Incident-365-6176-K05-43A-001.pdf |
| AL-50-022-22-1529-A-E | 12/11/2022 | ARCH INSURANCE GROUP CLAIMS DEPARTMENT | CMS-for-Incident-ZACAT7002902.pdf | |
| TX-CW-201-22-474598-EEEE | 12/16/2022 | GERMANIA INSURANCE COMPANY | GRACIE CLARK | CMS-for-Incident-2302211027945.pdf |
| TX-CW-201-22-474598-EEE | 12/16/2022 | GERMANIA INSURANCE COMPANY | JORDAN CARRIKER | CMS-for-Incident-2302211027945.pdf |
| TX-CW-201-22-474598-EE | 12/16/2022 | GERMANIA INSURANCE COMPANY | NATHAN WOOTEN | CMS-for-Incident-2302211027945.pdf |
| TX-CW-201-22-474598-E | 12/16/2022 | GERMANIA INSURANCE COMPANY | CMS-for-Incident-2302211027945.pdf | |
| Incident Number | Date of Loss | Insurance Company Name | Patient Name | CMS Claim Form |