____...

Planned Employee Program

Administered by

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I Medical Claim
Pi.... man completed form to: Principal Mutual Ute Inaurance' ComJHIny
Regional Claim Center One Lakeview Energy Center. Suite B40 3817 N.W. Expressway Oklahoma City. Oklahoma 73112 Telephone 1-4059495655 Toll free in Oklahoma 1-11005226608 Outside Oklahoma H30()'523-5665

Principal Mutual Ufe Inaurance Company

Des Moines. Iowa

Employee Directions for Completing Claim Form

1. For each new sickness or accident claim complete Parts A, B, and C below. 2. For continuing sickness or accident claims (where you previously have sent in a claim form for that sickness or accident) you need to complete only Parts A and C of this form. 3. Turn to reverse side of claim form and complete Patient's Name and sign Authorization To Pay if you wish benefits paid to Provider. 4. Have Patient's Physician or Supplier either complete their portion on the reverse side of claim form or attach an itemized bill that includes diagnosis. 5. If the hospital requests verification of coverage, the hospital may call Principal Mutual Life Insurance Company toll free Nationwide 800-247-4695. '

Part A
Employee's Name Dt\fJ I fL S - S U,_,_ \ \) 4,.) Employee's Employer Be$([ I $ 1-h41l..P Patient's Name(s) Is Employee still working? Yes No 0 If "No" date last worked Employee's Date of Birth

~J.:b_;.k.3..
_
_

i&

_Su:d'J77;J....L.CJ..S,e_~~

Spouse~Social Securi~ N~_~~~ Plan and 1.0. numbers (printed on Employee's 1.0. card): Part B

~~-~~~~~---~~--~~-~~ Plan 5S o4S"

L-

1.0.

444 #72-~4i "

,'" ~~>;;-7"~""'-:

.','

~~.

For whose expenses is ciaim being made? -self~ . Wife .._Patient's Date of Birth __j__j__ Patient's Occupation

0" H~;b~~~ 0 [i~ Son

Daughter 0

Step Child 0 ---;

FosterChild 0 -:-_

Patient's illness or injury (if injury, describe accident including date and place) (!}'~ck

v'< ~

"!'I ~ tv..J

" ,J "edate

p-r

til? t'1Md

.f~4minl1/ll1!
Yes

I"fSoL__

Date Patient's illness began __j__j Employee's employment Is spouse employed? Yes

Did Patient's injury or illness result from employment?

No
__

--i-J~ AI/
0
f.)--

Is Employee

Single

Married ~

Divorced

Widowed

0 0
_

If "Married", give spouse's name

Spouse's Date of Birth __j~

No

If "Yes" give name, address, and telephone no. of spouse's employer

Is patient covered by any other medical benefit plan, group policy, prepayment plan, Medicareor other Government plan? Yes 0 No 0 If "Yes" give name of Person carrying the other coverage --:-, _ Name of Group (employer, association, etc.) _ Name of Insurance Company or Plan Address of other Insurance Company's claim office These statements are true and complete to the best of my knowledge Policy or Plan No. -;;::-----:-_-;-;:---;-_-;-(Signature of Employee)

_ _
=-:-:(Date)

Part C In order to process a claim for benefits, I authorize any physician, hospital or other medical provider to release to Principal Mutual Life Insurance Company of Des Moines, Iowa, or its representative, any information regarding my medical history, symptoms, treatment,.examination results or diagnosis. A photocopy of this authorization shall be considered as effective and valid asthe original. This authorization shall be considered valid for the duration of the claim, but not to exceed one year from the datil signed. I undef7StandI have the right to receive a copy of this authorizati~. Date 12rl Signature of Employee 4"I/4AML.<{ 7'4r.~ -'.

JI

Signature of Patient Address of Employee

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117.f1::.;!?t. s.

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Cir;-f -

Ole
State

Is this a. new address? Yes

PE 365-2

ft1 No 0

Street No.

7400j Zip Code

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