• Use claim form C101.
• Complete the section entitled "Claimant's Statement". Be sure to date and sign the blanks provided at the bottom of the form.
• A copy of the police accident report is required for all accidents investigated by any law enforcement agency.
• Submit a copy of the hospital bill that includes the diagnosis and the number of days you were hospitalized.
• If you were treated in the emergency room or a doctor's office, please submit copies of those bills that show the diagnosis, the procedures performed (CPT codes) and itemized charges.

• In addition to the items above, the physician should complete PART B "Attending Physician's Statement" for dismemberment benefits.
• For accidental death benefits, the "Claimant's Statement" portion of claim form C101 should be completed by the beneficiary and the blanks provided at the bottom of the form should be dated and signed by the beneficiary. A certified copy of the death certificate is required.
• A copy of the police accident report is required for all accidents investigated by any law enforcement agency.

Disability Income Claims - See Disability