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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

City

6. Spouse Name

7. Spouse Birthdate

9. Are Other Family Members Employed?

Yes

No

State

4. Marital Status Single

Divorced

Married

Widowed

Zip Code

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?

Yes

No

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?

Yes

No

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

Sex

Spouse

M

Child

Patient Birthdate

Dependent Marital Status Single

F

Widowed

Other If Claim Is For Dependent Child 19 Or Older Is Child Enrolled As A Full Time Student?

Divorced

Married

Legally Separated

Name Of School Yes

No

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.

________________________

__________________________________________________

__________________________________________________

Date

Employee Signature

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


umr-medical-claim-form