Claim Form P.O. Box 37390 Louisville, Kentucky 40233-7690
Please refer to reverse side of this form for helpful information on how to file our claim. All claims must be filed during the benefit period or within 12 months following the end of the benefit period.

A  Patient and Member Information (Please Print)
Patient's Name: First -- Middle -- Last Patient's Birtdate  /  /  Phone Number Patient's Sex Area Code () Male  Female Patient's Relationship to Member: Self  Spouse  Child  Other: (Please Explain) If the patient is a full-time student, past his or her 19th birthday, please give school name	Member's Name: First - Middle - Last Member's Identification Number Member's Home Address - No. & St. City - State - Zip Code

B  Medical & Accident Information

Please give patient's diagnosis or description of medical condition: If accident related, please give date accident occurred:  /  /  Did the accident involve a motor vehicle?  Yes  No Did the accident occur while on the job?  Yes  No Describe the accident or injury:

C  Other Insurance   Complete This Section Only if the Patient was Covered by Other Insurance or Medicare (Attach Explanation of Benefits)

Name of Member Member's Identification No. Name of Member's Employer Other Insurance Company's Name Other Insurance Company's Address If the patient is eligible for Medicare, please give Medicare Identification Number.

D  Member's Signature and Date   (Attach Patient's Original Itemized Bills to This Form.)

I certify that the above information is complete and accurate to the best of my knowledge and that benefits are being claimed only for expenses incurred by the named patient. I understand that any intentional false statements or willful misrepresentations may result in legal prosecution. I authorize any provider of service in possession of any medical information concerning the patient to release such information to you upon request. I understand that itemized bills or statements submitted with a claim cannot be returned. Member's Signature   Date