subject_line

Benefits Claim Information Form

What type of Benefits Claim help is needed? *

Medical	Dental	Vision	Life
Short term disability	Long term disability	Aflac	Other Other

Name of Employer: *

Employee name: *

Date of Birth: * +

Employee Phone Number: *

Employee Email: *

Is the claim for a Dependent? *

Yes

No

Dependent name: *

Dependent Date of Birth: * +

Name of Insurance Carrier: *

Insurance ID Number: *

Date of Service: * +

Provider's Name: *

Provider's Phone Number: *

Brief description of the Issue: *