If you were directed to this website by your healthcare provider, it is because you were recently treated because of injuries sustained in an automobile accident, work related accident, or other accident. The registration staff of your treating facility does not have sufficient information to bill the proper insurance. Required fields are marked with an asterisk (*) symbol.
ACI uses this information to best help settle auto accdent insurance claims. Not all fields are required to be filled out. Please provide as much information as possible.
ACI uses this information to best help settle workers compensaton insurance claims. Not all fields are required to be filled out. Please provide as much information as possible.
ACI uses this information to best help settle insurance claims. Not all fields are required to be filled out. Please provide as much information as possible.
Please understand that ultimately you are responsible for providing this information so that the correct insurance can be billed. The purpose of this site is simply to provide a user friendly and convenient way to provide your treating facility this information.
To read more about the policies with this form click here.
Warranty Disclaimer. You acknowledge and agree that ACI provides the SUBMITPOLICYINFO Website to you free of charge and for your convenience. THE SUBMITPOLICYINFO WEBSITE AND THE CONTENT, MATERIALS, AND INFORMATION AVAILABLE ON THE SUBMITPOLICYINFO WEBSITE ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. ACI DISCLAIMS ALL REPRESENTATIONS AND WARRANTIES, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHERWISE, INCLUDING WARRANTIES OF MERCHANTIBILITY, ACCURACY, FITNESS FOR A PARTICULAR PURPOSE AND TITLE, AND THAT THE SUBMITPOLICYINFO WEBSITE OR CONTENT, MATERIALS, AND INFORMATION AVAILABLE THROUGH SUBMITPOLICYINFO WEBSITE ARE APPROPRIATE FOR YOUR USE OR ARE FREE OF VIRUSES, WORMS, OR OTHER HARMFUL COMPONENTS. You acknowledge and agree that data and information related to SUBMITPOLICYINFO Website will be transferred over the internet, ACI does not control such transfer of data, use of this information will be subject to limitations inherent in the use of the interest, and that ACI is not responsible for any delays, delivery failures, or other damage resulting from such problems.
Limitation of ACI's Liability. EXCEPT AS EXPRESSLY PROVIDED BELOW, ACI WILL NOT BE LIABLE TO YOU FOR ANY LOSS (TANGIBLE OR INTANGIBLE) OR DAMAGES OF ANY KIND ARISING FROM OR RELATED TO ACI'S OPERATION OF THE SUBMITPOLICYINFO WEBSITE OR YOUR USE OF THE SUBMITPOLICYINFO Website. UNDER NO CIRCUMSTANCES SHALL ACI BE LIABLE TO YOU FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, SPECIAL, PUNITIVE, OR EXEMPLARY DAMAGES, ARISING FROM OR RELATED TO ACI'S OPERATION OF THE SUBMITPOLICYINFO WEBSITE OR YOUR USE OF THE WEBSITE, REGARDLESS OF HOW THE DAMAGES ARE INCURRED OR THE THEORY OF LIABILITY, AND REGARDLESS OF WHETHER ACI HAD BEEN ADVISED, KNEW, OR SHOULD HAVE KNOWN OF THE POSSIBILITY OF SUCH DAMAGES.
Close Window