Follow the steps to successfully complete your application

1. To begin the process, click the ‘Get Form’ button to acquire the form, which you can then open in your preferred document editor.
2. Carefully read the instructions provided on the form to understand the requirements for submission. Remember, photocopies are not acceptable, and all charges must be itemized on the original bill.
3. If you have bills, submit them for reimbursement without having to pay them upfront, except for Assisted Living bills, which must be paid in full and accompanied by a receipt.
4. Input your details as the Head of Household, including your first and last name, social security number, and home address.
5. List the Claimants' names along with their respective information, such as dates of birth and social security numbers. Indicate if this is a new address by selecting 'Yes' or 'No'.
6. Determine the status of the Officer by selecting the appropriate option: ACTIVE, RETIRED, AUX CAPT, or RETIRED AUX CAPT.
7. If any expenses arose from an accidental injury, complete the specified items about the injured claimant and injury details, such as the nature and date of the accident.
8. Complete the authorization for the release of information by signing in the provided areas. This step is crucial as it allows Chesterfield to access the necessary information to process your claim.
9. If you wish to authorize payment directly to your medical provider, sign in the Authorization to Pay Provider section.
10. Once all fields are filled out, save your changes. You may then download, print, or share the completed form as needed for your records.

Take action now and complete your submission online to ensure you receive your benefits promptly.