Get Instructions For Application For Admission To Mmif.qxd - Colorado ...

This guide offers step-by-step instructions for completing the Application for Admission to the Colorado Major Medical Insurance Fund online. By following these directions, you will ensure that your application is filled out accurately and efficiently.

Follow the steps to successfully complete your application.

1. Click the ‘Get Form’ button to access the application form. This will allow you to open the form directly in the editor for easy completion.
2. Begin by entering your W.C. Number in the designated box. Click inside the field to type and use the tab key to navigate to the next field.
3. Next, fill in the Insurance Carrier name and the Claimant Name. Keep in mind that for each section, you should use numbers only where specified, such as for the Social Security Number.
4. Continue to the Carrier Claim Number and the Date of Accident/Injury fields. Ensure that your inputs are accurate to avoid delays.
5. Provide the Claimant’s Mailing Address, including street address or P.O. Box, state, and zip code. Take care to input each component in the correct field.
6. For the medical expenses breakdown, fill in the respective dollar amounts for each category, ensuring you type the period for cents where applicable. Complete the total at the bottom of this section.
7. If necessary, attach additional documentation on a separate sheet to substantiate the costs provided, excluding attorney fees or administrative costs.
8. Indicate whether you are aware of any third-party activity related to the claim by selecting 'Yes' or 'No'.
9. Lastly, secure the signatures of both the Claimant and an Insurance Carrier Representative. Make sure to include the date and contact numbers where indicated.
10. Once all fields are filled out, you can print the application. If needed, use the 'Clear Entire Form' button to remove all inputs and start over.

Complete your application form online today to ensure a smooth submission process.