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RS-19-03-TRV02Section 1: To be completed by claimant/insuredName of Claimant/InsuredPolicy NumberAddress (street, city, state, zip)Date of BirthPolicy Purchase DateTrip Departure DateGenderMaleFemaleAbout the ClaimantAbout the Patient - Complete only if different from InsuredName of PatientRelationship of Patient to InsuredWas patient traveling with insured? Ye sNoSection 2: To be completed by physicianDiagnosis / ICD-9 Code (primary diagnosis)Diagnosis / ICD-9 Code (secondary diagnosis)Date patient first consulted you for this conditionDate symptoms first appearedHas the patient ever had this condition before?

Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance ... Workers’ Compensation Claims Only: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent ... claim for disability compensation or medical benefits, or submits a false or ...

  Compensation, Worker, Alaska

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