Follow the steps to complete the claim form online

1. Press the ‘Get Form’ button to obtain the claim form and open it in your preferred editor.
2. Begin by answering the question about whether a claim has been filed before for this loss by selecting 'Yes' or 'No.'
3. Input the policyholder's full name, date of birth, and address including city, state, and ZIP code.
4. Provide the policy number and check the box if the address has changed.
5. Fill in the home and work phone numbers along with the social security number of the policyholder.
6. Enter the patient's full name, date of birth, and social security number. Indicate the relationship of the patient to the policyholder.
7. State whether the patient is a full-time student if applicable and select the type of claim you are filing.
8. Outline the sickness or injury being claimed, and list all doctors who have treated the patient for this condition.
9. If treatment has been received in the past for a similar condition, detail the physician's name and address.
10. For accidental injuries, provide the date, location, and time of the accident, and explain how it occurred.
11. Indicate if the injury occurred on the job and provide details about any work-related claims.
12. Complete sections related to hospitalization, including dates of admission and discharge, as well as the hospital name and address.
13. Fill in the dates of restrictions relating to work duties and indicate if the patient has returned to work, alongside any related dates.
14. Sign and date the authorization to release information allowing Bankers Fidelity Life Insurance Company to access necessary medical and employment records.
15. If claiming disability benefits, ensure the reverse side of the form is filled out by both the employer and attending physician.
16. Review all entries for accuracy, then save changes, download, print, or share the completed form as needed.

Complete your documents online for a seamless filing experience.