~~----------~------~---+------------~------Planned Employee Program

Administered by Principal Mutual Ute 1n8Ul'llnca Company Des Moines, Iowa

Ir

I Medical Claim

P ..... mell completed fonn to: Principal Mutual Ute In.ul'llnce Company Regional Claim Center One Lakeview Energy Center, Suite 840 3817 N.W. Expressway Oklahoma City, Oklahoma 73112 Telephone 1-405-949-5655 Toll free in Oklahoma 1-800-522-6608 Outside Oklahoma 1-800-523-5665

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 J)/hJ\i(:..L

$.

SVV_\~A-,J

Employee's DjUe of Birth ~~ Name(s)

(.3 _

Employee's Employer '3~ST, ShMp, Is Employee still working? Yes ~ No

Shw,dcw.t Strjf2.v>(. Patient's 0 If "No" date last worked

Plan

11~

Ill.

'::>.

S "" ; vPrN

~oo~~~~IS~~~~~~~-------------~----------~~~Plan and 1.0. numbers (printed on Employee's 1.0. Card):

L ...5 g 045
Son 0

1.0.

444

'J2-~ 4-g ,
FosterChild 0 _ _ Yes

Part B
For whose expenses is claim being made? Self 0 Wife 0 Husband0 Patient's Date of Birth __J__j__ Patient's Occupation Daughter 0 Step Child 0

Patient's illness or injury (if injury, describe accident including date and place) Date Patient's illness began Employee's employment Is spouse employed? Yes Did Patient's injury or illness result from emplovrnent?
__

__J__j

__

No
__

date

__J__J

Is Employee

Single

Married

Divorced

Widowed

0 0
_

If "Married", give spouse's name

Spouse's Date of Birth

__J__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, Medicare or 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. _ _

-----:==-:-:==:-::-:-;------"ii'-:::;----(Signature of Employee) IDate)

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 as the original. This authorization shall be considered valid for the duration of the claim, but not to exceed one year from the daft signed.j unqe,s~d I have the right to receive a copy of this authoriz~n. Date I Signature of Employee V' Lf~ ,/(1 ~ -

rj'i K

Signature of Patient Address of Employee

------s:-----d-.-~(R~eq~Ui~~7d~On~IY~i~tP~a7tie-nt~i-s-SP-ou-se~)---------

100010

E.

/17th (1,- _.

{;.; ( X 16V
Cilv'~

()

KState

1400';
Zip Code

Street No.

Is this a new address? Yes

PE 365-2

No ~
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