Follow the steps to fill out the ACI Claim Package online.

1. Click ‘Get Form’ button to access the ACI Claim Package and open it for editing.
2. Fill in the group plan or program name at the top of the form, followed by entering the policyholder’s details.
3. Input the policy number and the certificate or I.D. number as specified.
4. Provide the name of the insured individual, including last name, first name, and middle initial.
5. Complete the present address and home address sections, ensuring all fields like city, state, zip code, and country are filled out accurately.
6. Enter the telephone number of the insured individual, along with their date of birth and the date of the accident or sickness.
7. Describe the nature of the accident or sickness, and detail how and where the accident occurred if applicable.
8. Indicate if the insured is covered under any other insurance plan and provide the name of the insurance company and policy number if applicable.
9. Complete the authorization section allowing ACI to release information needed to process the claim.
10. Ensure the insured or parent’s signature is completed to authorize payment to the medical provider or third party.
11. Fill out the physician or provider information section thoroughly, including dates of first symptoms and treatment.
12. Attach all necessary documentation, including itemized bills and paid receipts, ensuring they are legible.
13. Review all entries for completeness and accuracy before saving changes.
14. Once completed, download, print, or share the ACI Claim Package as needed.

Complete and submit your ACI Claim Package online today for efficient processing!