Get Critical Illness Claim Form H-ici-gci-0911 - Supplemental Support

Submitting a critical illness claim can feel overwhelming, but this guide aims to simplify the process of filling out the Critical Illness Claim Form H-ICI-GCI-0911 - Supplemental Support online. Follow these detailed steps to ensure all necessary information is accurately provided.

Follow the steps to complete your claim form with ease.

1. Press the ‘Get Form’ button to acquire the Critical Illness Claim Form H-ICI-GCI-0911, which will open it for your online submission.
2. In Part 1, provide the requested policyholder or certificateholder information, including your full name, policy number, contact address, date of birth, social security number, and phone number. If there is a change in your address, be sure to check the accompanying box.
3. In Part 2, fill out the statement of loss. Enter the patient’s name, date of birth, social security number, and gender. Specify your relationship to the patient and describe the medical condition or sickness in detail.
4. Indicate the date of the first treatment for the described condition, and clarify whether the loss was due to an accident. If so, provide a brief description of the accident.
5. If applicable, provide hospitalization details, including the name, city, and state of the hospital. List all physicians who have treated the patient for the condition, including their names, addresses, and phone numbers.
6. Select the appropriate benefits claiming options: Lump Sum Benefit, Wellness Benefit, Hospital Confinement Benefit, Radiation/Chemotherapy Benefit, or Consultation Benefit. Be sure to include relevant details such as types of screening tests and dates.
7. Parts 3, 4, and 5 require completion by the relevant physician’s office. Ensure that the physician providing the statement fills out their information accurately and descriptively regarding the patient's condition.
8. Review all information entered into the form for accuracy before proceeding. Once satisfied, save your changes and consider printing the document for a physical copy.
9. Finally, download or share the completed form as needed to submit your claim according to your insurance provider’s guidelines.

Ready to submit your claim? Complete the Critical Illness Claim Form online today.