Based on a recent claim we received for medical treatment, it appears you may have had an injury related to an accident. In order to process your benefits claim, we will need more information. We appreciate your providing us with the information requested on this form.
If you have any questions, please don’t hesitate to contact Member Services at 800.547.0421, Monday through Friday from 7:30 a.m. - 3:30 p.m., Mountain Standard Time.
This form requires that you submit information related to your accident (ie. Police report, insurance declaration, etc.). Please make sure you have all of this information scanned and ready to submit with this form. Your claim cannot be processed until we receive all the required information.
PLEASE NOTE: We are not affiliated with your employer. Therefore, we will not share any information with any third party without your prior, written consent.
IF YOUR CONDITION IS NOT DUE TO AN ACCIDENT, please click HERE.