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Get Part 2 Employeemember Statement Please Print
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How to fill out the PART 2 EMPLOYEEMEMBER STATEMENT Please Print online
Filling out the PART 2 EMPLOYEEMEMBER STATEMENT is an essential step in submitting your extended health claim. This guide will provide clear instructions to help you accurately complete the form online, ensuring that you don't miss any critical details.
Follow the steps to successfully complete the EMPLOYEEMEMBER STATEMENT
- Click ‘Get Form’ button to access the EMPLOYEEMEMBER STATEMENT. This action will allow you to open the document in an online editor.
- Begin by filling in your group policy number and account number at the top of the form. These numbers help identify your claim.
- Enter your name in the designated field. It is important that you print your name clearly to avoid any confusion.
- Provide your date of birth in the specified format (D/M/Y). This information is necessary for identity verification.
- Complete your mailing address, ensuring that each field is filled out accurately. Include your previous name if applicable.
- Indicate the amount paid for the expense in the corresponding section. Take care to include all amounts accurately.
- Fill out the date the expense was incurred in the appropriate field. This must also be in (D/M/Y) format.
- In the 'Description of Expense' section, provide a detailed account of the expenses that you are claiming.
- Answer the questions regarding other benefits. If you have claims pending from other companies or sources, ensure to name them accurately.
- If applicable, indicate if you wish any unpaid balance of this claim to be reimbursed under your Health Spending Account.
- For students aged over 18, provide their names and education details, including enrollment status and dates.
- Carefully read the certification statement at the bottom of the form, confirming that all information is true. After reviewing, sign and date the form.
- After completing the form, you can save your changes, download it, print a copy, or share it as needed.
Complete your EMPLOYEEMEMBER STATEMENT online today to ensure your health claim is processed efficiently.
This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.
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