Get Il Mutual Bd-164 2019-2025

Filling out the IL Mutual BD-164 form online can seem daunting, but with clear guidance, you can complete it confidently and accurately. This form is essential for submitting an accident insurance claim and requires specific information to process your claim effectively.

Follow the steps to complete your IL Mutual BD-164 form.

1. Click the ‘Get Form’ button to access the form and open it in the online editor.
2. Begin by entering the policy number and claim number in the designated fields.
3. Fill out the claimant’s information section. Enter your name, select your gender and marital status, and provide your date of birth. Specify your relationship to the policyowner by selecting one of the options.
4. In the policyowner’s information section, input the name, address, and contact details of the policyowner, including cell phone and email.
5. Detail the accident information. Enter the date of the accident and identify whether it was an on-job or off-job accident. Include the date of initial medical treatment and provide a descriptive account of the accident.
6. Gather and submit the required documentation. Attach itemized bills, emergency room reports, operative reports if applicable, and the hospital bill showing diagnosis and charges. If the claimant is deceased, include a certified death certificate.
7. If you are claiming based on supplemental benefits, mark the appropriate boxes and follow any additional instructions for each specific rider.
8. Complete the Off Job Accident Only Disability section if applicable. Answer all required questions related to employment.
9. Sign and date the claim form, ensuring all information is accurate. Include additional information regarding your relationship to the policyowner if you are not the policyowner.
10. Review your completed form for accuracy. Save your changes, and then download, print or share the form as needed.

Complete your insurance claim documents online today for quick processing.