V10 97 Claim Form – Fill Out and Use

CENTRAL UNITED LIFE INSURANCE COMPANY

INVESTORS CONSOLIDATED INSURANCE COMPANY

CLAIM FORM

CAUTION: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.

PART A TO BE COMPLETED BY PATIENT (INSURED)IMPORTANT: ALL QUESTIONS MUST BE COMPLETED AND FORM SIGNED

Insured’s Name						Social Security No.
Street Address			City or Town				State		Zip Code
Office Phone No.		Date of Birth		Marital Status				Sex: Male	!
								Female	!
IF A DEPENDENT CLAIM
Dependent’s Name				Date of Birth				Relationship
Are you entitled to an income tax exemption for this dependent? Yes ! No !
If child, is he/she employed?		Yes ! No ! Name of employer

Sex: Male ! Female ! If child is over 19 years old, is child a full-time student? Yes ! No !

Name of school

Are you or your dependent entitled to benefits under: Any other vision plan? Yes ! No !		Medicare Yes ! No !
If yes, name of family member holding policy			Policy No.
Name and address of employer, union, association, school, etc., carrying other plan
Name and address of other insurance company

PLEASE SIGN AND DATE AUTHORIZATION

I accept this claim form and authorize release of information relating hereto. I certify the truth of all personal information contained above and that all the services listed above have been completed/delivered. I agree to be responsible for the applicable co-payment as detailed in my Group program, for any services indicated as rendered. I also agree to be responsible for any and all services which may be rendered but not eligible for coverage under my Group Program.

Patient (Parent or Subscriber Signature)

Date

AUTHORIZATION TO PAY BENEFITS TO PROVIDER: I hereby authorize payment directly to the Provider of the Vision Benefits for the services as described on this claim but not to exceed the scheduled amount of covered vision care expenses for these services.

Insured Person (Signature)Date

TO BE COMPLETED BY AMERICAN STATES INSURANCE

Eligibility and status approved by Central United Life/Investors Consolidated Insurance Companies

Claims Administrator

Date

V-10/97

COMPLETE AND RETURN

THIS FORM PROMPTLY

Central United Life Insurance Company

Investors Consolidated Insurance Company

P.O. Box 925309

Houston, TX 77292-5309