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Get Seven Corners Injury And Illness Claim Form

: To be considered, claim form and receipts for expenses must be submitted within 90 days of the date of service!!! Instructions: 1. This form is to be used when filing a claim for reimbursement of Medical Expenses and must be completed by the Insured in full. 2. Fully itemized bills including Claimant s Name, Nature of Illness/Injury, must be included with this claim form. 3. Description and Charge for each service provided. 4. This form must be signed and dated in all applicable sections. I.

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