Universal Claim Form Template

Download a blank fillable Universal Claim Form Template in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Universal Claim Form Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

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UNIVERSAL CLAIM FORM
Member’s Name ( Last)
(First)
(Initial)
(from ins. Card)
Policy#:
Group#:
Home Address
Home Tel #:
Business Tel #:
Name of Patient
Patient’s SS#:
Patient’s Birth Date:
Was injury or condition related toL
Patient’s Employment? ____(YES) _____(NO)

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Parent category: Legal
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