Insurance Information Form

A doctor sits at her desk and smiles as she works on paperwork

This form is to help you obtain the information that is needed for us to submit your insurance claim. Please fill out so we can accurately update your account information. To contact Customer Service, please call 1-800-494-5797.

If you come to a Trinity Health Michigan site to be treated as a result of a motor vehicle accident (excluding motorcycle involvement) whether you were a driver, a passenger or a pedestrian, according to the Michigan State No-Fault Law, you must contact the appropriate auto insurance company and report your injuries in the following sequence this applies regardless of whose fault the accident was:

STEP 1: Personal No-Fault Policy. If you do not have your own personal auto insurance, then report injuries according to step 2
STEP 2: Spousal No-Fault Policy: if you do not have a spouse or your spouse does not have auto insurance, then report injuries according to step 3
STEP 3: Residential Relative Policy: if there is not active auto insurance with any resident relative, then report your injuries according to step 4
STEP 4: Policy issued to Owner/Registrant of Occupied Vehicle: if the owner/registrant does not have auto insurance, then report injuries according to step 5
STEP 5: Policy Issued to Driver of Occupied Vehicle: If the driver does not have auto insurance, then report injuries according to step 6
STEP 6: Michigan Assigned Claims Plan (MACP): michacp.org

Please be advised that the following information is needed in order to submit the claim. If not received, you will be billed for this service.