SOCIAL SECURITY NUMBER (optional)
CHECK BOX IF THIS IS A NEW PERMANENT ADDRESS
PLACE OF EMPLOYMENT:
ACCIDENTAL INJURY CLAIM FORM
SECTION A: POLICYHOLDER/PATIENT INFORMATION
Accidental Injury Only
Deceased - Date Deceased:___/___/___
Complete Section A: Policyholder/Patient Information.
Have your doctor complete Section B: Physician's Statement. If you are filing for disability, have your doctor also complete and sign Section C:
Physician's Disability Statement.
If you are filing for disability, have your employer complete and sign Section D: Employer's Disability Statement.
Be sure to sign your claim form at the bottom of Page 1.
Submit all bills related to this claim such as ambulance, follow-up visits, physical therapy, etc. All bills should be itemized and should include the
diagnosis, services rendered and actual charges for the service.
If you were treated in the emergency room, send us a copy of the emergency room report.
We require a copy of the police accident report for all motor vehicle accident claims and other incidents investigated by any law enforcement agency.
Send a copy of your hospital bill that lists the number of days confined.
If confined to an intensive care unit, please send a copy of your hospital bill that shows charges and the number of days you spent in the intensive care
unit. Your intensive care claim cannot be processed without the hospital bill.
Please include a certified copy of the death certificate if the patient is deceased.
Be sure to include your policy number(s) on all documents.
Date of incident: _____/_____/_____
Describe where and how the incident occurred:_____________________________________________________
** If the injury re