[ ] Initial Reimbursement Request

[ ] Subsequent Reimbursement Request

Group Name:

Policy Eff Date:

Employee Name:

SSN #:

Claimant Name:

Relationship:

Claimant Original Effective Date:

Claimant Date of Birth:

Is Claimant eligible under any other insurance? [ ] No  [ ] Yes

Ins Name:

Is Claimant on COBRA? [ ] No  [ ] Yes

COBRA Effective Date:

ICD-9 Code:

Diagnosis Description:

Is claim due to [ ] illness  [ ] accident  [ ] work-related  [ ] MVA  [ ] subrogation involved?

Please furnish details:

Was employee actively at work on Stop Loss effective date? [ ] Yes  [ ] No

If claimant is the employee, what was the work status during the period claims were incurred?

Is treatment continuing? [ ] Yes  [ ] No

If yes, what is the expected Claim Total: $

Is this a pre-existing condition? [ ] Yes  [ ] No

Total benefits paid by TPA this submission:

$

Less specific deductible:

$

Reimbursement requested:

$

Prepared by:

Date:

TPA Name:

TPA Address:

TPA Phone:

TPA Fax: