English Language Institute / China
INSTRUCTIONS Fill out your claim form completely. (Complete Sections 1 through 4)
Have your doctor complete an HCFA 1500.
Attach itemized bills for hospital, attending physician, surgeon, prescriptions, etc., if claim is filed for these benefits.
Employee Medical Claim Form
SECTION 1 To Be Completed By Employee On All Claims 1. Employee Name
3. Employee Birthdate
2. Employee Social Security No.
5. Employee Address
6. Spouse Name
7. Spouse Birthdate
9. Are Other Family Members Employed?
4. Marital Status Single
8. Spouse Social Security No.
10. If Yes, Name And Address Of Employee In Item 9.
Soc. Sec. No. 11. Do You Or Your Dependents Have Any Other Coverage?
If Yes To Item 11, Name And Address Of Other Insurance Company And Policy Number
If Yes To Item 11, Name Of Insured 12. Is The Condition The Result Of An Accident?
If Yes, How, Where And When (Date) Did It Occur?
SECTION 2 To Be Completed By Employee If Claim Is For Dependent Name Of Dependent
Relationship To Employee
Dependent Marital Status Single
Other If Claim Is For Dependent Child 19 Or Older Is Child Enrolled As A Full Time Student?
Name Of School Yes
SECTION 3 To Be Completed On All Claims Incurred Outside of the U.S. Date of Service
Name of physician or facility where services were received
Diagnosis, or name of prescription
Country where medical care received
Currency indicated on medical bill
SECTION 4 To Be Completed By Employee On All Claims I Declare The Foregoing Answers And Statements To Be True And I Authorize Any Person Or Institution Rendering Care Or Any Person Or Organization In Possession Of Insurance Or Other Benefits Information For _________________________________________________________________ Name of Patient (Please Print) To Furnish To UMR, Or Its Representatives Full Information Regarding Such Care, Insurance Or Other Benefit Information. A Photocopy Of This Authorization Will Be Valid As The Original.
Patient's Signature (Parent, If Minor)
Mail completed claim to: UMR
Claims toll-free number:
PO Box 30541 Salt Lake City, UT 84130-0541 Benefits, claims and e-mail inquiries: Visit www.umr.com or e-mail UMR-MedicalBenefits@umr.com
800-826-9781 OR 715-841-2260