Please read the form carefully and enter your responses accurately.

Incomplete or missing information can delay the processing of your claim.  Also, please note the following;

Box 2:        Master Policy Number is C528F

Box 26:      Health Center Referral – You are encouraged to utilize the Health Center whenever possible, however, you are not required to do so.  If you did not visit the Health Center in relation to this claim, check the appropriate box.

Make certain that you sign three places:

- Payment Authorization,

- Medical Authorization

- As the Insured at the bottom of the page

On page 2 of the form, please complete as much of the Statement of Other Insurance as applies to you.  Check off all that apply in Box 9.