Transcription of ACCIDENT CLAIM FORM - ngah-ngic.com
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ACCIDENT CLAIM FORM - ngah-ngic.com
Page 1 of 2 ACCIDENT CLAIM FORM Instructions: Please complete all sections, sign and date, then mail or fax this for m with the following information to the contact information at top right. In order for your CLAIM to be expedited, we need all the requested information at time of CLAIM . Bills for treatment of this ACCIDENT along with any ACCIDENT reports Police report for automobile accidents Bills containing the diagnosis and procedure codes Emergency Room notes/discharge paperwork, if applicable Operative report for surgical claims, if applicableSECTION 1: Claimant s Information Claimant s relationship to policy owner Self Spouse Dependent Last Name First Name MI Address City State ZIP Policy No.
Page 1 of 2 ACCIDENT CLAIM FORM Instructions: Please complete all sections, sign and date, then mail or fax this form with the following information to the contact information at top right.
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