ICC Insured Questionnaire

Welcome to the Optum on-line injury questionnaire. We are investigating to determine if any other party or insurance carrier may have responsibility to pay for the medical treatment noted on the letter directing you to this website. The information we are requesting relates only to the incident referred to in that letter. We respect your right to privacy and will handle the information you submit with utmost discretion.

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We'll need the following information about the work incident

If your Worker's Compensation claim has been denied, please provide us with a copy of the denial.

You can either Mail, or Fax us a copy.
Fax: 920-662-8340
P.O. Box 13216
Green Bay, WI 54307-3216