Follow the steps to complete the questionnaire properly.

1. Click the ‘Get Form’ button to access the Questionnaire and open the document in your preferred online editor.
2. Begin by entering your personal information in the designated fields, including your member name, member ID number, telephone number, date of birth, and address. Ensure all details are accurate to avoid processing delays.
3. Indicate who the claim is being made for by selecting the appropriate option: yourself, spouse, or dependent. Complete the associated name and date of birth fields as required.
4. If the claim is due to an accident, injury, or incident, provide detailed information about the event, including the date, location, property owner details, and whether a claim has already been filed. Attach any relevant documentation, if applicable.
5. Determine if the claim is related to a work-related injury or illness. If it is, ensure you have filed with your worker’s compensation carrier and provide the necessary details on the form.
6. If you own a business or work with another employer, fill out the relevant business information, including the name, type, address, and contact details.
7. For claims resulting from a motor vehicle accident (MVA), complete the designated section, confirming if a police report was filed, and ensure you have filed with your auto insurance first. Attach copies of the police report and your insurance policy as instructed.
8. Review all provided information for accuracy. After confirming that all sections have been filled out completely, sign and date the form as the final step before submission.
9. Once you are satisfied with the information, you can save any changes, download, print, or share the completed form as required.

Take the next step in managing your claim — fill out your AR Initial Accident Injury Illness Questionnaire online today.