Member Claim Form
COBRA*
537237a Rev. 5-05
FAMILY/OTHER COVERAGE INFORMATION:
Complete only if claim is for a dependent and/or other coverage is in effect
NOTE:
X
NAME OF HEALTH INSURANCE COMPANY
EFFECTIVE DATE OF COVERAGE
EMPLOYEE INFORMATION: Employee complete this section
If yes, provide:
X
POLICY NUMBER
TYPE OF PLAN (HMO OR PPO) IF KNOWN
C. DESCRIPTION OF HOW ACCIDENT OR WORK RELATED ILLNESS/INJURY OCCURRED
PATIENT INFORMATION: Complete only if patient is other than employee
ACCIDENT/OCCUPATIONAL CLAIM INFORMATION:
Complete only if claim is a result of an accident or occupational (work related) illness/injury
YES
NO
NO
YES
NO
YES
NO
YES
NO If yes, Name of Third Party:
F. EMPLOYER NAME
TELEPHONE #
A. EMPLOYEE’S NAME (Last Name, First Name, Middle Initial)
E. ACCOUNT NO. (on the front of your CIGNA ID card)
YES
Other
Child
NO
D. CIGNA ID NUMBER OR EMPLOYEE SOCIAL SECURITY NUMBER
(on the front of your CIGNA ID card)
YES
SPOUSE EMPLOYED?
A. PATIENT’S NAME (Last Name, First Name, Middle Initial)
E. PATIENT’S ADDRESS - IF DIFFERENT THAN EMPLOYEE ADDRESS (No., Street)
SPOUSE’S DATE OF BIRTH
IF NO, HAS SPOUSE BEEN EMPLOYED
DURING LAST 12 MONTHS?
B. INJURY DUE TO
AUTO ACCIDENT?
DISABLED*
IS THIS A CHANGE OF ADDRESS?
(Note: address must also be changed with Employer)
A. ACCIDENT OR ILLNESS
DUE TO EMPLOYMENT?
B. RELATIONSHIP TO EMPLOYEE
STUDENT FULL-TIME
*EFFECTIVE DATE
G. EMPLOYEE STATUS
Please be aware that if the provider of service holds a contract with CIGNA, payment will always be made to the provider even if this
section is not signed. If the provider is contracted with CIGNA, the provider will be paid by CIGNA at the contracted rate. If you have
already paid for services, you should seek reimbursement directly from the provider.
D2.
(City)
B. NAME OF SPOUSE (Last Name, First Name, Middle Initial)
E.
EMPLOYEE’S SIGNATURE
N/A
B. DATE OF BIRTH
EMPLOYED FULL-TIME
F.
C. DATE OF BIRTH
IF YES TO D1. OR D2. AND THE OTHER INSURANCE IS PRIMARY, ENCLOSE A COPY OF THE EXP