Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the form and open it in an editable format.
2. Begin by entering the name of the policyholder in the designated field.
3. Input the policy number accurately as provided in your documentation.
4. Fill in the name of the insured individual. This refers to the person covered under the insurance policy.
5. Indicate the class associated with the insurance policy, if applicable.
6. Provide the complete address of the policyholder, including city, state, and ZIP code.
7. Enter the social security number of the insured.
8. List the occupation of the insured individual in the relevant section.
9. Record the date the insured last worked and the current employment status.
10. Input the rate of base earnings, excluding overtime, commissions, or bonuses, selecting from hourly, weekly, monthly, or annually.
11. Document the date employed and the date the insurance became effective.
12. Fill in the dependent’s effective date if applicable.
13. Specify the principal sum of the insurance policy.
14. If the insurance has been terminated, provide the reason for termination in the specified field.
15. Indicate whether the injury was sustained in connection with employment by selecting 'Yes' or 'No' and provide an explanation if 'Yes' was selected.
16. Choose where to mail the benefit check, either to the employer or the beneficiary, including any necessary copies to the administrator/employer.
17. Sign the certification section, confirming the accuracy of the information provided, and include the date.
18. Provide the name, title, address, and phone number of the authorized representative if applicable.
19. Complete the statement of beneficiary by entering their name, address, age, and social security number.
20. Fully describe the accident, including specific details of what occurred, and utilize additional paper if necessary.
21. Sign the authorization for information release and include your relationship to the deceased.
22. Read the applicable statement for your state and provide your signature and date at the bottom.
23. Mail the completed claim form along with the insured person’s enrollment forms, beneficiary designation, certified copy of the death certificate, and any relevant articles to the specified address.

Take the time to complete your documents online today for a more efficient claims process.