CLAIMANT’S STATEMENT AND AUTHORIZATION

MULTINATIONAL UNDERWRITERS, INC.

107 South Pennsylvania Street, Suite #402

Indianapolis, Indiana 46204


PART A: Complete for all claims.
Insured Name: Patient Name:
Sex: Birthdate: Sex: Birthdate:
Street Address: City: Postal Code:
State: Country:
Home Telephone: Work Telephone: Fax Number: E-mail address:
Group Number: Certificate Number:

1. Is the Patient: A U.S. Citizen?    Yes   No    If yes, how many months of the year are you in the US? ________

2. Is the Patient: A full-time Student?   Yes     No    If yes, please provide the name and address of school:______________________________________________________

3. Is the Patient: Employed?   Yes     No    If yes, please provide the name and address of employer:___________________________________________________________

4. Do you or any family members have other coverage (medical, indemnity or liability)
which might help cover hospital and medical expenses?   Yes    No
If yes, please provide the following:
Name of Company: Address:
Policyholder: Policy Number:
Is this group insurance?    Yes     No
PART B: Complete for new claims. If you need additional space, please attach additional sheets.
  1. How did the condition begin? State fully all symptoms and describe the condition in detail from the beginning:
  2. When did the first symptoms of this condition begin. State the exact date, if possible:
  3. Have you ever had or been treated for the same kind of illness or injury?   Yes   No If Yes, when? Name, address and telephone number of attending physician:
  1. Name, address and telephone number of family physician (even if not consulted):
  2. What ailments, diseases, illnesses, conditions or injuries have you had during the last five years? Please provide name and/or description of each condition, dates involved, and the name, address and telephone numbers of attending physicians:

    3.  

     
     
     
     
     
     
     
     
     
     
     

  3. Is the condition the result of an accident or illness:
a.) Related to employment?    Yes    No If yes, are you applying for Workers Compensation benefits?   Yes    No
  1. Involving a motor vehicle?   Yes   No    If yes, list the names of involved parties, insurance carriers and policy numbers:
Was a police report filed?    Yes     No    If yes, with what agency?
PART C: Complete for all claims.

I verify that all information contained in this form is true, correct and complete to the best of my knowledge. I authorize any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance company, group policyholder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or mental condition, or the financial or employment status of the insured named below, to provide this information to MultiNational Underwriters, Inc. I understand that I have the right to receive a copy of this authorization upon request. A copy of this shall be as valid as the original. This authorization is valid for twelve months from the date signed:
 
Signature of Insured:
Print Name: Date:
Signature of Patient:
Print Name: Date:

AUTHORIZATION: I authorize payment of medical benefits to the doctor or other supplier of services submitting the attached bills.
 
Signature of Insured: Date:

DIRECTIONS FOR SUBMITTING A CLAIM

  1. If this is a new claim, complete ALL PARTS of this form.
  2. If this is a continuing claim, complete Parts A and C only.
  3. Attach all original itemized bills for services and supplies. Please verify that the documents indicate your name, date of service, diagnosis and the charge for each service.
  4. Mail to: MultiNational Underwriters, Inc.

    5. 107 South Pennsylvania Street, Suite #402
    Indianapolis, Indiana 46204
  5. If you have any questions, please call 1-800-605-2282. If calling from outside the US, call collect to (317)262-2132.
INDIANA LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete or misleading information commits a felony.