Follow the steps to successfully complete the questionnaire:

1. Press the ‘Get Form’ button to access the questionnaire and open it in your preferred editing tool.
2. Begin by filling in your personal details, including your name, date of birth, school name, insurance ID number, and mailing address.
3. Indicate your gender and provide your email address and other relevant details such as visa type and home country.
4. If you are completing the form on behalf of a student, fill in the student’s name, date of birth, and your relationship to the student.
5. For claims resulting from an injury or accident, indicate the date the injury occurred and provide as many details as possible about the incident.
6. If applicable, state whether the injury was due to intercollegiate or intramural sports and specify the sport.
7. For claims related to sickness, provide the name and address of the treating physician and any prior treatment history for the condition.
8. List all current medications you are taking and indicate if you have any other insurance coverage.
9. Review the authorization section carefully and provide your electronic signature by typing your name and insurance ID number in the given spaces.
10. Finalize your submission by saving the changes. You can download, print, or share the completed form as necessary.

Complete your online claim submission today to ensure timely processing of your insurance issues.