P.O. Box 37390
Louisville, Kentucky 40233-7690
Please refer to reverse side of this form for helpful information on how to file our claim.
All claims must be filed during the benefit period or within 12 months following the end of the benefit period.
A Patient and Member Information
Patient's Name: First -- Middle -- Last
Area Code (
Patient's Relationship to Member:
Other: (Please Explain)
If the patient is a full-time student, past his or her
19th birthday, please give school name
Member's Name: First - Middle - Last
Member's Identification Number
Member's Home Address - No. & St.
City - State - Zip Code
B Medical & Accident Information
Please give patient's diagnosis or description of medical condition:
If accident related, please give date accident occurred:
Did the accident involve a motor vehicle?
Did the accident occur while on the job?
Describe the accident or injury:
C Other Insurance
Complete This Section Only if the Patient was Covered by Other Insurance or Medicare
(Attach Explanation of Benefits)
Name of Member
Member's Identification No.
Name of Member's Employer
Other Insurance Company's Name
Other Insurance Company's Address
If the patient is eligible for Medicare, please give Medicare Identification Number.
D Member's Signature and Date
(Attach Patient's Original Itemized Bills to This Form.)
I certify that the above information is complete and accurate to the best of my knowledge and that benefits are being claimed only for expenses incurred by the named patient. I understand that any intentional false statements or willful misrepresentations may result in legal prosecution. I authorize any provider of service in possession of any medical information concerning the patient to release such information to you upon request. I understand that itemized bills or statements submitted with a claim cannot be returned.