Claim Form - Burba Insurance Services printable pdf download

Claim Form - Burba Insurance Services

INSTRUCTIONS FOR SUBMITTING A CLAIM

The form has two parts; the Claimant’s Statement and the Attending Physician’s Statement. When completing the

form, keep in mind you can prevent the potential of a delay by providing complete and accurate information.

Please complete all answers on the Claimant’s Statement that are applicable to your claim. When you ask the

doctor to complete the Physician’s Statement, verify that the questions are answered and that it is signed and

dated. We understand your need for a timely benefit payment.

Below are some of the more common documents and bills that are needed when filing a claim for a given type of

policy. The suggested documents are not comprehensive. Refer to your policy benefits to help determine what

bills should be submitted for consideration.

If you need help when completing your claim form, have questions about what documents need to be submitted, or

need claim forms in the future, our customer service representatives will help you. Please call them Monday

through Friday between 7:00 AM and 5:00 PM, Central Standard Time. Their telephone number is 800-251-

7254.

Cancer, Specified Disease, Hospital & Heart. Submit the completed form along with your itemized hospital

bills, doctor bills, (surgery, anesthesia, inpatient attending physician bills) chemotherapy, and radiation therapy

bills. On claims for cancer and specified disease, submit the first pathology report diagnosing your condition.

Intensive Care. Submit the completed form along with your itemized hospital bill or the UB92 hospital bill.

Accident/Disability. Submit the completed form along with your itemized bills, including emergency medical

treatment. They must include a diagnosis. If a police report was prepared, please provide it. If you are only

filing for accident medical expense benefits, it is not necessary to have the Attending Physician’s Statement

completed.

Please return the completed claim form and bills to the following address:

Worksite Marketing Division

P. O. Box 8043

Little Rock, AR 72203-8043

FAX: 1-501-371-3196

FORM WMD4741 R 6/01

Claim Form - Burba Insurance Services