EBU Specific Claim Request

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

REQUEST FOR SPECIFIC REIMBURSEMENT

[ ] 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

Documentation to be enclosed with all initial Requests for Reimbursement:

Copy of actual enrollment card reflecting the initial effective/hire date
Patient claim form and attending physician statement(s)
Legible copy of completed EBU claim worksheet(s)
Legible copy of claim drafts showing payments issued
Legible copy of all supporting bills to be issued
Copies of all investigation material requested
Pre-Cert documentation
COBRA election form and copies of COBRA payment
Signed subrogation letter and police report
Proof of applied deductible and out-of-pocket prior to this policy year

Total benefits paid by TPA this submission:		$
Less specific deductible:		$
Reimbursement requested:		$
Prepared by:		Date:
TPA Name:
TPA Address:
TPA Phone:	TPA Fax:

(ebumpr.aug2000-S8.2)