Confirmation Of Treatment

Per your conversation with our team, we are sending you this “CONFIRMATION OF TREATMENT (COT)” template based on your completion of medically necessary treatment(s) for injuries sustained from your claim. The COT serves as a confirmed list of facilities and providers you received specialized care from for your accident related injuries. As part of the COT process, we are asking that you fill out the fields below to move forward with the next steps of your claim.


Treatment Providers(Required)

Name of Provider/Facility Address Phone Number Treatment Date From Treatment Date To Actions
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