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Member Claim Form
COBRA*
591692a Rev. 10/2008
FAMILY/OTHER COVERAGE INFORMATION:
Complete only if claim is for a dependent and/or other coverage is in effect
NOTE:
X
NAME OF HEALTH INSURANCE COMPANYEFFECTIVE DATE OF COVERAGE
EMPLOYEEINFORMATION:Employee complete thissection
If yes, provide:
X
POLICY NUMBER
TYPE OF PLAN (HMO OR PPO) IF KNOWN
C. DESCRIPTION OF HOW ACCIDENT OR WORK RELATED ILLNESS/INJURY OCCURRED
PATIENT INFORMATION:Completeonly if patient is otherthanemployee
ACCIDENT/OCCUPATIONAL CLAIM INFORMATION:
Complete only if claim is a result of an accident or occupational (work related) illness/injury