Follow the steps to complete the Form Abj21476 online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering your certificate holder or claimant information. This includes fields for your certificate number, first name, middle initial, last name, social security number, date of birth, age, mailing address, and phone number. If your address has changed, check the box indicating a new address.
3. Provide your e-mail address, employer details, occupation, and job responsibilities. You will also need to indicate whether premiums for the certificate were paid with pre-tax dollars by selecting 'Yes' or 'No'.
4. If the claimant differs from the certificate holder, provide the claimant's detailed information, including their first name, relation to the insured, date of birth, and age.
5. In the accident claim details section, describe your diagnosis or condition, when symptoms began, and answer questions regarding your condition's work-relatedness, whether it was an accidental injury, and the details of the accident.
6. Fill in the specifics about the incident, including the date, time, what caused the injury, where it occurred, and whether a police report was filed.
7. Provide details regarding your physician visits, including dates and reasons for each visit, and whether you missed work due to the accident.
8. Select the benefits you believe may be due from the list provided, ensuring that you attach all required documentation that substantiates your claims.
9. Complete the certification section by reading and signing to confirm that all information provided is accurate. Include the date of signing.
10. If applicable, fill out the assignment of benefits section, specifying to whom the benefits should be sent.
11. Once you have completed the form, review it thoroughly to ensure all information is correct before saving changes, downloading, printing, or sharing the form.

Start filling out your documents online today and ensure a smooth claims process!