Form Abj10367ny-5 - Wellness Claim Form - 2015
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1
2CLAIM FORM AND INSTRUCTIONS
If you have any questions regarding benefits available, or how to file your claim, or if you
would like to appeal any determination, please contact our Customer Care Center at
1-866-541-5794, 8:00 A.M. to 8:00 P.M. Eastern Standard Time
The furnishing of this form, or its acceptance by the Company as proof, must not be construed as an admission of any
liability on the part of the Company, nor a waiver of any of the conditions of the insurance contract.
INSTRUCTIONS FOR FILING WELLNESS CLAIMS
•
To avoid delays in processing please fill out the sections which apply to your specific claim.
•
Include your policy number(s). To obtain your policy number(s) call 1-866-541-5794.
•
You may fax your claim to us at 1-866-427-3623. Please be assured that your claim will receive our immediate
attention. If you would like to receive your claim proceeds even faster, Allstate Benefits can automatically deposit
them into your bank account by completing and returning our ACH form (ABJ16661NY).
Please contact our
Customer Care Center to obtain a copy of our ACH form.
•
Allstate Life Insurance Company of New York
You may mail your claim to:
Allstate Benefits Service Center
P.O. Box 331429
Atlantic Beach, Florida 32233
POLICYHOLDER
1. First Name:
Middle:
Last Name:
E-mail:
Policy Number:
Social Security Number:
Date of Birth:
/
/
Male
Female
MO/DAY/YR
2. Home Number: (
)
Avg. Monthly Earnings:
PATIENT’S INFORMATION
3. Name: First:
Middle:
Last:
4. Date of Birth:
/
/
Age:
Social Security Number:
Male
Female
MO/DAY/YR
5. This person is your:
(ex: self, wife, son, etc.)
WELLNESS EXAM
INSTRUCTIONS FOR FILING WELLNESS CLAIMS:
Please attach the physician, clinic, or facility receipt showing the specific wellness exam performed and date it
was provided. Thank You.
ABJ10367NY-5
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Allstate Life Insurance Company of New York (Home Office: Hauppauge, NY)
PO Box 331429 Atlantic Beach, Florida 32233 Phone 1-866-541-5794
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