Get Empire Claim Form

This guide is designed to help you navigate the process of filling out the Empire Claim Form online. Follow the steps and detailed instructions to ensure that your claim is completed accurately and efficiently.

Follow the steps to complete the Empire Claim Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's information in Section 2. Fill in the last name, first name, and middle initial of the patient. Ensure accuracy in this section, as it is crucial for processing the claim.
3. Enter the patient's birth date in Section 3 using the MM/DD format. This information helps verify the identity of the patient.
4. In Section 5, provide the patient's complete address, including street number, city, state, and zip code. Check for typos to avoid complications.
5. Section 6 requires you to indicate the patient’s relationship to the insured. Select one of the options: Self, Spouse, Child, etc.
6. In Section 7, if the insured has a different address than the patient, provide that information, too.
7. Move to Section 8 and indicate the patient’s current status by ticking the appropriate box.
8. Complete Section 9 with the name of any other insured, if applicable.
9. In Section 10, respond to whether the patient’s condition is related to employment, auto accidents, or other accidents. This is vital for determining coverage.
10. Continue to fill out Sections 11 through 26 with pertinent information about the insured’s policy numbers, group numbers, and any other relevant details about previous insurance plans.
11. In the final sections, ensure to sign and date the form at Sections 12 and 13, authorizing release and payment of necessary benefits.
12. Review all entries for accuracy, then you may choose to save changes, download, print, or share the completed form for submission.

Start filling out your Empire Claim Form online today to ensure timely processing of your claim.