Direct Bill to Insurance Application

BILL TO INSURANCE FORM (#6)

BILL TO (INSURANCE COMPANY'S NAME)

INSURANCE COMPANY'S ADDRESS

Address Line 1

Address Line 2

City

Province

Zip Code

Country

CONTACT PERSON AT (INSURANCE COMPANY)

CONTACT PERSON'S JOB TITLE

CONTACT PERSON'S PHONE NUMER AT (INSURANCE COMPANY)

Extension number

CONTACT PERSON'S FAX NUMBER AT (INSURANCE COMPANY)

CONTACT PERSON'S EMAIL ADDRESS AT (INSURANCE COMPANY)

INVOICE WILL BE SENT VIA

BILLING EMAIL

BILLING FAX NUMBER

WHO IS SETTING UP THIS ACCOUNT ?

NAME OF THE PERSON SETTING UP THIS ACCOUNT

Email Address

Phone Number

COMPANY

COMPANY'S ADDRESS

Company's Address

Address Line 2

City

Province

Zip Code

Country

PASSENGER'S INFORMATION

CLIAIM NUMBER

PASSENGER'S FIRST NAME

PASSENGER'S LAST NAME

PASSENGER'S HOME PHONE NUMBER

PASSENGER'S CELL PHONE NUMBER

PASSENGER'S EMAIL

PASSENGER'S ADDRESS

Address Line 1

Address Line 2

City

Province

Postal Code

Country

DOES CUSTOMER NEEDS WHEELCHAIR ACCESSIBLE VEHICLE ?

WHO WILL BE BOOKING THE TRIPS ?

ARE THERE ANY RESTRICTION TO TRAVEL

Yes

TRAVEL RESTRICTIONS

TRANSPORTATION FOR MEDICAL APPOINTMENTS ONLY

Yes

RISTRICTED TO SPECIFIC ADDRESSES

Yes

IF RESTRICTED TO SPECIFIC ADDRESSES PLEASE LIST:

OTHER RESTRICTIONS

Yes

LIST ANY OTHER RESTRICTION:

I have read and agree to the Terms and Conditions and Privacy Policy

PRINT NAME OF INSURANCE ADJUSTER