Form Cli 8292 PDF Details

Form Cli 8292 is a U.S. Customs and Border Protection form used to request information about specific merchandise being imported into the United States. This form can be used to request information such as the Harmonized Tariff Schedule (HTS) number for the product, its value, and other technical details. The use of Form Cli 8292 may be necessary if you are looking to import a product that is not listed in the Automated Commercial Environment (ACE), or if you need more detailed information about a specific product. For more information on this form, and how to fill it out, please continue reading.

QuestionAnswer
Form NameForm Cli 8292
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesaflac dental claim form, certify, aflac dental claim forms, aflac dental form

Form Preview Example

This form should be filled out The Cincinnati Life Insurance Company

completely and sent to: Life & Health Claims Department Fax: (513) 870-2969

HEALTH INSURANCE CLAIM FORM

TO BE COMPLETED BY ASSOCIATE

 

Name of associate:

______________________________________

 

Sex: M

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

_______________________________________________

 

Date of birth:

_____________

 

ABOUT YOU

City:

__________________________

State:

_____

 

 

Zip:

________

 

 

Single

 

 

 

 

 

 

 

 

 

 

 

Check

Married

 

Clock #:

_________________

Home tel. no.: (

____

)

___________

 

 

 

 

 

 

One

Divorced

 

Business no.: (

____

)

_______________

Extension:

____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Legally Separated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is patient:

Yourself

 

 

 

 

Name of dependent:

_______________________________

 

 

 

 

 

 

 

 

 

 

Your Spouse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth: Month

______

 

 

Day

______

 

Year

______

 

 

 

 

 

 

 

 

 

 

 

 

Your Child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent’s employer, if any:

_______________________

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ABOUT THE

If other, explain:

________________

 

________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_____________________________

 

 

Is dependent child a full-time student?

Yes

No

PATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If “Yes,” indicate name of school:

____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is dependent child married?

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim is for: Doctor

_________________________

Hospital

_______________________________

 

 

 

 

Is this bill a result of a sickness?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this bill a result of an injury?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did sickness or injury arise out of or in the course of employment?

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ABOUT THE

If bill was the result of an injury:

Date injury occurred:

__________________________________

 

 

 

 

 

 

 

 

 

 

 

 

CLAIM

 

 

 

 

 

 

 

 

 

Where injury occurred:

_________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How injury occurred:

__________________________________

 

 

 

 

Was the injury the result of an automobile accident?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

Name of other insurance company:

__________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you, your spouse or your dependent children entitled to benefits from any other kind of health

 

insurance plan, including union welfare plans or school insurance?

 

Yes

 

 

No

 

 

 

 

 

 

 

If “Yes,” answer A and B below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ABOUT OTHER

 

 

 

 

 

 

 

 

 

 

 

 

A.

Identify family member insured under other policy:

____________________________________

 

 

INSURANCE OR

 

 

 

 

 

 

 

 

 

 

 

 

B.

Name of other insurance company:

_______________________

 

 

Policy no.:

_____________

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

_____________________________________________

 

 

Effective date:

__________

 

 

REIMBURSEMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

________________________________________________

 

 

State:

_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip:

_________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

Is the CFC Health Plan: Primary

 

 

Secondary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I will abide by the provisions set forth in the Summary Plan Description and Plan Document.

I certify the above is complete and correct and that I am claiming benefits only for charges ASSOCIATE’S incurred by the patient named above.

SIGNATURE

Associate’s signature ___________________________________ Date ___________________

ATTENTION

Any person who intends to defraud or knowingly facilitates fraud against an insurer by submitting an

application or filing a claim containing a false or deceptive statement is guilty of insurance fraud.

Form CLI-8292 (11/05)

How to Edit Form Cli 8292 Online for Free

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Step 1: First of all, open the tool by pressing the "Get Form Button" at the top of this webpage.

Step 2: After you launch the PDF editor, you'll notice the document prepared to be completed. Other than filling out different blank fields, you could also perform several other things with the form, such as writing custom text, modifying the original textual content, inserting illustrations or photos, putting your signature on the form, and more.

This PDF will require specific data to be typed in, hence you should take your time to enter exactly what is asked:

1. Start completing your aflac dental forms with a selection of essential blanks. Gather all the information you need and make certain absolutely nothing is omitted!

aflac dental form conclusion process shown (part 1)

2. The third step is usually to submit these blanks: Claim is for Doctor Hospital Is, Was the injury the result of an, Yes, Are you your spouse or your, Yes, ABOUT THE, CLAIM, ABOUT OTHER, INSURANCE OR, OTHER, REIMBURSEMENT, C Is the CFC Health Plan Primary, Secondary, and I will abide by the provisions set.

Completing section 2 of aflac dental form

Always be extremely careful while filling out Yes and Claim is for Doctor Hospital Is, since this is the section where most users make errors.

Step 3: Right after looking through the form fields, click "Done" and you're good to go! Grab your aflac dental forms as soon as you subscribe to a free trial. Quickly view the pdf file inside your FormsPal account page, together with any modifications and adjustments being conveniently saved! We don't share or sell the information you enter when completing forms at our website.

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