Continuum Recovery Services Insurance Verification Form

Insurance Verification
Name of Person Completing Form*
Phone Number of Person Completing Form*

Area CodePhone Number
Client Full Name*
Client Date of Birth*
(mm/dd/yyyy)
Primacy Policy Holder Information
Primary Policyholder's Full Name (if applicable)

First NameLast Name
Primary Policyholder's Date of Birth (if applicable)
Insurance Company*
Policy Number*
Group Number (if applicable)
Insurance Telephone Number

Area CodePhone Number
Address of Policyholder*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Should be Empty: