» Insurance Information

The form below will allow you to submit insurance information for your ambulance transport directly to our billing department.

Please provide us with the necessary information to file a claim in the section below. If your injury was due to an automobile accident, we need both automobile insurance and health insurance information.

If you have any questions, feel free to call us at (256) 261-9184 for assistance.

Date of Transport
Run # (Can be found at top right of invoice)
Auto Insurance Company
First Last
Address Line 1
Address Line 2
City
State
Zip
Adjuster Name
Claim Number
Insurance Phone Number
Health Insurance Company
First Last
Address Line 1
Address Line 2
City
State
Zip
Policy Holder's Name
Policy Number
Group Name
Phone Number