The Allstate Wellness Claim Application form is a 2-page document that guides Allstate policyholders through the process of filing a claim for their annual wellness benefits. The form covers preventative screenings and HPV vaccinations that qualify under your policy.
To complete the form, you will need to provide the insured's name, social security number, policy number(s), patient's date of birth, and contact information. The form includes a list of covered screenings from blood tests for cancer markers to echocardiograms and mammograms.
An optional assignment of benefits section lets you direct payment to a provider rather than receive it yourself (not available in New Hampshire). A detailed authorization section allows the release of medical information needed to process the claim. Fraud warnings for multiple states appear at the bottom of the form, outlining the legal consequences of submitting false information.
| Question | Answer |
|---|---|
| Form Name | Allstate Wellness Claim Application Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | allstate insurance exclude operator form, MAINE, allstate wellness claim online, ABJ10367 |