Policy Number(s): | |
Patient's Name: | |
Patient's Date of Birth: | |
Patient's Social Security Number: | |
Mailing Address: | |
City: | State: ZIP: |
Home Phone: | |
Work Phone: | |
Cell Phone: | |
Fax: | |
E-mail: | |
Desired Contact Method: | |
Additional supporting information required:
- The physician’s, clinic, or facility receipt showing the specific wellness exam performed and the date it was performed. You may:
- upload it below; or
- fax it to us at 1-800-693-7507; or
- mail it to us at P. O. Box 703, Elba, AL 36323.
- If filing under a Critical Illness policy, we will also need the charge for the exam.
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Please read our fraud disclaimer before submitting:
Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.
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Select a file to upload with your claim form:
If uploading a file, please be patient after clicking the submit button to allow the file time to upload.
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