Claims Workflow Request (V. 02.26.24) "*" indicates required fields Step 1 of 3 33% Questions regarding billing, refunds, denial of enrollment, and "will this claim be paid" should not be directed to the Claims Department. Doing so will only create a delay or frustration for the caller. <<Please be sure to address all coverages before you end the call>>Agent Submitting Request*Enter your name.Servicing Location*Where you are located.Select your locationManilaEl Paso, TXClaims Specialist Call Back or Claim Forms*Reminder: •A call back from a Claims Specialist takes 1-2 business days •Emailed claims forms can take up to 24-hours •Mailed claims forms can take 10 to 14 business days Note: Claim packets cannot be emailed for Transamerica insuredsPlease Select One OptionClaims Specialist Call Back OnlyClaims Packet OnlyCall Back Reason*Please Select One OptionQuestions on Completing Claim PacketClaim Packet NeededClaim StatusBilling QuestionWill My Claim Be PaidQuestions on Claims Process Please Do Not Submit This Request: Workflows should not be submitted to the Claims Department related to questions about billing, product exclusions, or to ask "Will this claim be paid?" The Claims Team is not able to answer those questions. The agent should refer to scripting in the Knowledge Base. Caller Information Caller's Name*The name of the person who called. First Middle Last Phone*The phone number of the person who called.Spanish callback required*Spanish is the preferred language for a callback.NoYesIs the Caller the Primary Insured*If the caller is the Primary Insured, select "Yes". If the caller is not the Primary Insured, select "No".Select OneYesNoCaller's Relationship to Primary*This is the relationship of the caller to the Primary Insured. (Example: Spouse or Child).Select OneCH: ChildPI: Primary InsuredSP: SpouseOT: Other Customer / Member Information Primary Insured's Name*The name of the Primary Insured. First Middle Last Coverage ID*The Coverage ID starts with a 6, 7, or 8 and is 9-digits. The Coverage ID will NOT contain any letters.Deceased or Injured Name*The name of the person the claim is being filed on. First Middle Last Relationship of Injured/Deceased to Primary Insured*This is the relationship of the person the claim is being filed on to the Primary Insured. (Example: Spouse or Child).Select OneCH: Child/ChildrenPI: Primary InsuredSP: Spouse Claim Information Packet Delivery Method*Select Delivery MethodUSPS MailEmailEmail*The email address of the person who called. Who Should the Packet be Addressed To?*Claim Packet Mailing Address*The address to where the caller wants the Claim Packet to be sent. Note that this is also the address used in the event an emailed claim packet cannot be delivered. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Insured's Mailing Address*The Primary Insured's mailing address. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Product*The type of Product the Primary Insured has. Select OneAD&D or APPHAPRecuperative Care / Daily Hospital ConfinementTermSITLPKGAccidental DeathAccident InsuranceCritical IllnessDismemberment Claim or Death Claim*If AD&D, APP, or AD, please select if the claim is for dismemberment, death, or family leave.Please Select OneDismemberment ClaimDeath ClaimFamily LeaveRemember to cancel all policies if the Primary Insured is deceased.Dismemberment Type*Please Select OneLH-Loss of HearingLL - Loss of LimbLSI - Loss of SightLSP - Loss of SpeechClaim Date Requirements Product Date of Accident Date of Loss AD&D Date of Injury Date of Death or Dismemberment TERM Date of Injury Date of Death PKG Date of Injury Date of Death HAP Date of Injury First Treatment Date RECUP Date of Illness First Treatment Date Critical Illness Date of Diagnosis Date of Diagnosis Injury Care Date of Injury First Treatment Date Date of Accident / Event*This date will need to be precise if a claim packet is requested and no call back. Please refer to the Claim Date Requirement chart by Product Date of Loss*This represents the actual date of loss and may be after the accident. Please refer to the Claim Date Requirement chart by Product. Cause of Claim*The reason for filing the claim on the Deceased or Injured person. (Example: Fall, Sick, etc.)Cause of Recuperative Care ClaimThe reason for filing the claim.Please Select OneSicknessAccidentCause of ClaimComaHeart attackInvasive CancerParalysisStroke
