Name of Dependent: Relationship to Member: Date of Birth:
Insured’s Name
Policy Number:
Zip CodeStateCity
Spouse’s Date of Birth: Spouse’s Social Security Number:
Is Dependent employed?
Group Insurance Company or Plan’s Name:
Group Insurance Company or Plan’s Address:
Name of Spouse:
Is the Patient Covered by Any Other Insurance, Prepaid Health Plan, Medicare, or Other Governmental Plan?
Complete if Claim is for DepenDent
Yes No If yes, state Name of Employer:
Yes No
Name of Sickness or Injury: Date Accident Occurred or Sickness Began: Date First Treated:
If Hospitalized, Name of Hospital: Date Admitted: Date Discharged:
Did someone intentionally cause this injury? Was injury due to an accident?
Was this due to an auto accident?
Have you led this claim under Workmen’s Compensation?
Did the accident happen on your property?
Did injury or illness occur in the course of employment?
Have you started a lawsuit related in any way to this injury/illness?
Have you received any settlement, payment, recovery of benets, including insurance company or policy, related in any way to this injury/illness?
Have you hired an attorney to represent you regarding this claim?
for all Claims:
Yes No Yes No
Yes No
Yes No
Yes No If no, address where accident occurred:
Yes No
Yes No
Yes No
Yes No
I hereby make claim for benets and certify that the above statements are true and correct to the best of
my knowledge and belief. I authorize the above named institution or physician to release information concerning
my enrollment, related records and medical records to the National Roofers Union & Employers Joint
Health & Welfare Fund.
Insured Member’s Signature Signed Date
National Roofers Union & Employers Joint
Health & Welfare Fund
initial report of Claims
This form is to be completed by the member. Complete
member’s section fully. Be sure to show your Social
Security Number and sign member’s signature section.
Remember to attach itemized bills.
Return completed form to:
National Roofers Union & Employers Joint
Health & Welfare Fund
3001 Metro Drive • Suite 500
Bloomington, MN 55425
952-854-0795 • Fax 952-854-1632 • 1-800-622-8780
Home Phone
Date of Birth Social Security Number Occupation
Home Address City State Zip Code
If claim is for members disability, show date last worked: Date resumed work:
member Completes this seCtion
Name of Member
This form does not have to be completed if you can furnish the Administrator with a complete itemized and
coded statement of services from the doctor.
If you do not have a complete itemized and coded statement, your doctor may use this form to report his
services and charges.
To collect disability benets, your doctor must complete questions, 1, 2, 4, 5, 7, 8 and 9 and sign and date
this form.
Attending Physician’s Statement
Attending Doctors Statement
1. Diagnosis and concurrent conditions (if diagnosis code other than ICDA used, give name)
2. Is condition due to injury or sickness arising out of patient’s employment?
4. Date symptoms rst appeared or
accident happened
5. Date patient rst consulted you
for this condition
6. Has patient ever had same or similar condition? If Yes, when and describe
8. Patient was continuously totally disabled (unable to work)
Doctors Signature
Providence State
Taxpayers identication Number
9. Date patient should be able to return to work,
if still disabled
( )
Zip Code
7. Is patient still under your care for this
10. Does patient have other health coverage? If Yes, please identify
Print Doctors Name
Street Address
Is condition due to pregnancy? If Ye, approximate date pregnancy commenced
3. Report of services (or attach itemized bill. If previous form submitted to this carrier, you need to show only dates and services since last report).
Date of
Place of
Procedure Code - If Used
If code other than
CPT used, give name
Ofce Use Only
Description of Surgical or Medical
Services Rendered
Yes No
Yes No
+O = Doctor’s Ofce IH = Inpatient Hospital
H = Patient’s Home OH = Outpatient Hospital
NH = Nursing Home OL = Other Location
ICDA = International Classication of Diseases
CPT = Current Procedure Terminology (current edition)
Total Charges $
Amount Paid $
Balance Due $
To be completed and signed by the Member if direct payment by Fund to surgeon or physician is desired. (This
assignment may not be honored if signed by a dependent or person other than the Insured Member.)
I hereby authorize the National Roofers Union & Employers Joint Health & Welfare Fund to pay directly to the
above named hospital or physician the Medical or Surgical Expense Benets to which I am entitled under the
terms of the Group Policy.
Member Assignment (Please Read Before Signing)
DateInsured Members Signature Signed