EMPLOYER BENEFIT UNDERWRITERS, INC.

100 LaCosta Lane, Suite 120, Daytona Beach, FL  32114
Phone (386) 274-2600 * Fax (386) 274-4111 * Email: Claims@ebu-inc.com

CLAIM WORKSHEET  

Group Name:

Policy Eff Date:

Employee Name:

SSN #:

Claimant Name:

Relationship:

Claimant Original Effective Date:

Claimant Date of Birth:

     

Date of Service

Provider

Reported Charges

Eligible Charges

Coins/Copay

TPA

Paid Date

TPA

Paid Amt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes/Comments:

 

 

 

Prepared by:

Date:

TPA Name:

TPA Address:

TPA Phone:

TPA Fax:

(ebumpr.aug2000-S8.3)