Please refer to reverse side of this form for helpful information on

GROUP NUMBER: 0081656-0081657
Part A – Patient & Employee Information
(Please Print or Type)
Patient’s Name: Last-First-Middle
Patient’s Birthdate
Employee’s Name: Last-First-Middle
Phone Number
Area Code (
Patient’s Sex
Employee’s Identification Number
Male … Female
Employee’s Home Address
Patient’s Relationship to Member:
Zip Code
Part B – Medical & Accident Information
Please give Patient’s diagnosis or description of medical condition:
If accident related, please give date accident occurred:_______________/__________/
Did the accident involve a motor vehicle? … Yes
Describe the accident or injury:
Did the accident occur while on the job?
Part C – Other Insurance
Complete this Section only if the patient is covered by other insurance or Medicare.
(Attach Explanation of Benefits from Other Insurance Company)
Name of Covered Person
Other Insurance Company Name
Covered Person’s Social Security Number
Name of Covered Person’s Employer
Other Insurance Company Address
If patient is eligible for Medicare, please give Medicare Identification Number
Part D – Employee’s Signature & Date (Please attach patient’s original itemized bill to this form)
I certify that the above information is complete and accurate to the best of my knowledge and that benefits are being claimed only for expenses
incurred by the named patient. I understand that any intentional false statements or willful misrepresentations may result in legal prosecution. I
authorize any provider of service in possession of any medical information concerning the patient to release such information to you upon
request. I understand that itemized bills or statements submitted with a claim cannot be returned.
Employee’s Signature________________________________________________ Date_______________________
Please refer to reverse side of this form for helpful information on how to file your claim.
Helpful Information for Filing Your Claim
Complete all requested information in sections A, B, C, and D on this claim form. A separate
claim form should be used for each family member. Claim form must be signed and dated by
the employee.
Attach all original itemized bills for the patient to this claim form. Obtain photocopies of
items needed for your records, as original bills will not be returned to you.
If the patient also is covered by any other health insurance or by Medicare, please attach the
Explanation of Benefits that corresponds to the itemized bills.
Mail your completed claim form with itemized bills to:
PO Box 266
Onalaska, WI 54650-0266
Points To Remember
Any person who knowingly and with intent to defraud any employee benefit plan or plan
representative files a statement of claim containing any materially false information or conceals,
for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent act, which is a crime.
For accurate claims processing we must be able to identify each service you received, when it was
received, who provided the service, and the amount charged. Because many bills list more than
one service, make sure that all bills are properly itemized. Canceled checks and receipts of
payment do not contain the information outlined below and are not acceptable.
Claim forms are available from your employer. Participating providers are required to file claims
directly with us.
Every Health Care Provider’s Bill Must Include the Following:
Provider’s name and address on a preprinted bill form or the provider’s original signature
Patient’s full name
Date each service was received (month, day, year)
Description of each service
Amount charged for service