Get Part 1 Group Accident Insurance Claim Form

Filing a claim for group accident insurance can feel overwhelming, but this guide will help you navigate the PART 1 Group Accident Insurance Claim Form with ease. By following these detailed steps, you will ensure that your form is completed accurately and submitted efficiently.

Follow the steps to successfully complete your claim form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin with SECTION 1, to be completed by the employer. Fill in the employer name, subsidiary or division name, group report number, and the complete address including city, state, and ZIP code.
3. Provide contact person information in the designated fields which include the first name, last name, phone number, fax number, and email.
4. Continue to fill out the employee information section. Make sure to enter the employee's first name, middle name, last name, employee ID number (if applicable), social security number, date of hire, job title, and work home phone numbers.
5. Indicate if the employee’s condition is work-related. If applicable, provide the workers' compensation details including the carrier name, claim number, and contact person information.
6. Complete SECTION 2, which is for the employee. Input personal information including their full name, social security number, date of birth, address, home phone number, marital status, and federal tax status. Specify the date the disability began and if it is due to an illness or injury.
7. In SECTION 3, the attending physician or provider will need to complete their part. They should provide patient information, dates of disability and treatment, diagnosis codes, and comments on the treatment plan.
8. Once all sections are filled out, ensure that all individuals involved sign and date their respective sections. This includes the signatures of the employer, employee, and physician/provider.
9. Carefully review all completed information for accuracy and completeness before proceeding to submit the form.
10. After completion, you can save your changes, download, print, or share the form as needed to submit it to the appropriate address provided in SECTION 4.

Get started on filling out your PART 1 Group Accident Insurance Claim Form online today!