Follow the steps to complete your claim form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the claimant's statement, which includes details such as the insured's full name, date of birth, policy or certificate number, social security number, address, and phone number.
3. Provide the employer's name and work phone number, then follow with the patient's full name and their relationship to the insured.
4. Inquire about the patient's medical history by responding to questions regarding the nature of the injury or illness, including when symptoms first appeared, and if they have had a similar condition previously.
5. List the name and address of all physicians consulted and indicate if the patient has Medicare, Medicaid, or other health insurance.
6. If the patient has been hospitalized for this condition, provide details including the admission and discharge dates, along with the hospital's name and address.
7. If applicable, include information regarding surgery, including the surgeon's name and address, and if the patient was confined to an Intensive Care Unit.
8. Document any dates the patient was unable to work due to this condition, including any requests for waiver of premium.
9. Complete the attending physician's statement by informing about the patient's diagnosis, medical consultation dates, and any previous similar conditions.
10. Finally, ensure all signatures are collected, including fraud warning acknowledgments as required for your state, then proceed to save changes, download, print, or share the form as needed.

Complete your Transamerica Worksite Marketing form online today to ensure a smooth claims process.