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LOS ANGELES COUNTY FIREMEN’S RELIEF ASSOCIATION
CLAIM FOR HOSPITAL BENEFITS
To Board of Directors; I_________________________________________________ Employee No.____________
(Print Name)
Of Station No. __________ Shift _____, or other work location _________________________________________
Residing at _________________________________________________________________________________ _
(Street) (City) (Zip) (Telephone)
A member in standing, hereby certify that I was admitted to the hospital because of:
___________________________________________________________________________________________
(State nature of illness or injury)
from _____________________20_____ to ______________________20_____
(Date of hospitalization) (Date of discharge)
I understand that the disability for which I am now claiming benefits from the Association is not service
connected. In the event this disability or its cause should hereafter be determined to be service connected. I
will promptly refund all benefits I have received pursuant to this claim.
The hospital claim does not include
the day of discharge. I have read and understand the above statement.
Please include a copy of the hospital discharge papers or a copy of the portion of the
hospital bill, reflecting the date of admission and the date of discharge. No hospital claim
shall be paid without proper supporting documentation.
Members Signature: _______________________________________ Date: __________
(Please sign and date)
Send Check to: __________________________________________________________
(Street Address or P.O. Box)
__________________________________________________________
(city) (Zip)
*SEE REVERSE SIDE FOR INFORMATION AND MAILING INSTRUCTIONS.
DO NOT WRITE IN SPACE BELOW
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
START DATE: __________ END DATE: __________ # OF DAYS: _________ AMT. PD: __________ CH. NO.________ DATE PD._________
VERIFY: MEMBER __________
DOCTOR __________
PAYROLL _________
Revised 01/08