A completed claim form is required each year. To prevent any delays in processing your claims, it is important to answer all questions in each section completely. It is important to give us complete information regarding your spouse and if you or your dependents are covered under another insurance plan. Please be sure the annual claim form is signed and dated.
Yes. The bill we received for you or your dependent has a diagnosis that indicates that the office/hospital visit may be due to an injury or accident. Please answer each question and indicate that this was not due to any specific accident or injury.
Yes. If you did not get hurt on the job, please indicate when, where and how your injury or accident occurred. If a third party other than your employer is involved, please give the third-party information that is requested.
Yes. This information must be verified annually to make sure an injury or accident did not occur since you filled out the form last year.