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Get FSL Hospital Confinement Indemnity (GAP) Claim Form 2014

1-1301 – fax Email: customerservice@specialinc.com CHECKLIST 1. 2. 3. Complete STATEMENT OF INSURED below, answering all questions fully. ATTACH EXPLANATION OF BENEFITS (EOB) provided by the insurer for your Comprehensive Major Medical Plan, if applicable, to this claim form. Return this claim form, all itemized bills and EOBs to the address shown above. STATEMENT OF INSURED Your Name Male Policy Number Social Security Number Your Address (Number and Street) Phone Number City State .

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