Information Needed to Complete the Form
Your personal Member information is needed to complete the form.
The Plan number (70682) must be included on the form. In addition, information such as:
Please follow the instructions on the form.
- details of the sickness and/or accident,
- the physician's contact information,
- details of your current condition,
- information on other benefits to which you may be entitled, and
- the signature of a witness is also required.