Group Name:

Policy Eff Date:

Employee Name:

SSN #:

Claimant Name:

Relationship to Emp:

Claimant Original Effective Date:

Claimant Date of Birth:

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

Ins Name:

ICD-9 Code:

Diagnosis Description:

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

Please furnish details:

First treated:

Current treatment:

Physician:

Telephone:

Address:

Prognosis: [ ] Poor    [ ] Fair    [ ] Good    [ ] Recovering    [ ] Deceased

Additional details:

Paid to Date: $

Pending Payment: $

Expected Claim Total: $

Is LCM involved? [ ] Yes  [ ] No     Is it [ ] Open  [ ] Closed?

LCM Company Name:

Telephone:

Contact Name:

Fax Number:

If not in LCM, what hospital savings were obtained? [ ] PPO  [ ] Negotiated

Prepared by:

Date:

TPA Name:

TPA Address:

TPA Phone:

TPA Fax:

For use by Employer Benefit Underwriters, Inc

Date
Received:

Claimant
ID:

Initial
Reserve:

Claims
Examiner: