Get Attention: Claims Department

This guide provides detailed instructions on how to effectively complete the Attention: Claims Department form online. Whether you have previous experience with such forms or are new to this process, the following steps will ensure you fill it out correctly and efficiently.

Follow the steps to complete the claims form successfully.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling out the Employee's Statement section. Enter your full name in the 'Full Name (Last, First)' field and provide your Social Security Number. Ensure your street address, date of birth, city, state, and zip code are accurately filled in.
3. Input your telephone numbers; include both home and work, if applicable. Specify your occupation and select your gender.
4. Describe the nature of your accident or sickness in the provided field. Indicate whether the claim is for an accident or sickness, and include the date of your first treatment.
5. If applicable, provide details about the accident, including how it occurred, the accident date, time, and place.
6. List the names and addresses of all doctors consulted regarding your condition, alongside the dates treated. Indicate whether you have had a similar condition before, and if so, give particulars.
7. Authorize the release of information by signing and dating the authorization section. Ensure you understand the implications of this authorization.
8. Complete the Employer's Statement part by providing necessary employer-related details, including group policy number, dates of hiring and last worked, and indication of eligibility for benefits.
9. If applicable, fill out the Attending Physician's Statement with the relevant diagnosis, treatment dates, and restrictions.
10. After completing all necessary sections, review all entries for accuracy and completeness. Save your changes, and consider downloading or printing the form if needed.

Complete your documents online and streamline your claims process today.