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Incident Questionnaire (Member Version) - Home | Visitor
www.premera.comP.O. Box 327 | MS 227 | Seattle, WA 98111 An Independent Licensee of the Blue Cross Blue Shield Association 005077 (09-2015) 1 of 2 To avoid possible delay in processing your claims, please complete, sign, and return this questionnaire within 45 days of receipt.