Accident Insurance Urgent Care Reimbursement Claim Form
Submit the details and documents needed to request reimbursement for an urgent care visit related to an accident.
Claimant and Policy Information
Claimant Full Name
*
First Name
Middle Name
Last Name
Policyholder Status / Relationship to Policyholder
*
Please Select
Policyholder
Spouse/Partner
Dependent Child
Other Family Member
Authorized Representative
Other
Policy Number / Policy Reference
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Accident and Urgent Care Visit Details
Accident Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Accident Description and How the Injury Occurred
*
Urgent Care Visit Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Urgent Care Facility Name
*
Reason for Urgent Care Treatment or Injury Treated
*
Reimbursement Request and Supporting Documentation
Total Amount Requested for Reimbursement
*
Preferred Reimbursement Method
*
Check
Direct Deposit
Other
Upload Itemized Urgent Care Bill or Receipt
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload Supporting Claim Document
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Claim
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