Claim Form - Burba Insurance Services


The form has two parts; the Claimant’s Statement and the Attending Physician’s Statement. When completing the
form, keep in mind you can prevent the potential of a delay by providing complete and accurate information.
Please complete all answers on the Claimant’s Statement that are applicable to your claim. When you ask the
doctor to complete the Physician’s Statement, verify that the questions are answered and that it is signed and
dated. We understand your need for a timely benefit payment.
Below are some of the more common documents and bills that are needed when filing a claim for a given type of
policy. The suggested documents are not comprehensive. Refer to your policy benefits to help determine what
bills should be submitted for consideration.
If you need help when completing your claim form, have questions about what documents need to be submitted, or
need claim forms in the future, our customer service representatives will help you. Please call them Monday
through Friday between 7:00 AM and 5:00 PM, Central Standard Time. Their telephone number is 800-251-
Cancer, Specified Disease, Hospital & Heart. Submit the completed form along with your itemized hospital
bills, doctor bills, (surgery, anesthesia, inpatient attending physician bills) chemotherapy, and radiation therapy
bills. On claims for cancer and specified disease, submit the first pathology report diagnosing your condition.
Intensive Care. Submit the completed form along with your itemized hospital bill or the UB92 hospital bill.
Accident/Disability. Submit the completed form along with your itemized bills, including emergency medical
treatment. They must include a diagnosis. If a police report was prepared, please provide it. If you are only
filing for accident medical expense benefits, it is not necessary to have the Attending Physician’s Statement
Please return the completed claim form and bills to the following address:
Worksite Marketing Division
P. O. Box 8043
Little Rock, AR 72203-8043
FAX: 1-501-371-3196
FORM WMD4741 R 6/01


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