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Get Teamcare HW8AA 2020-2021

CLAIM FORM - INITIAL REPORT OF DISABILITY FORM MUST BE COMPLETED IN FULL BEFORE PAYMENT IS CONSIDERED Remit To: TeamCare, PO Box 5107 Des Plaines IL 60017-5107 or Fax Form To: 847-518-9757 SECTION 1 PARTICIPANT S INFORMATION Participant s Identification Number: 8 0 PLEASE PRINT Participant s Full Name: Date of Birth: 6 Participant s Complete Address: Employer: Date of Accident: If accident related, please answer the following questions: Where did the accident occur? Home.

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