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Superimposed Major Medical Claim Form - OSAunion - osaunion 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin with Section A, where you will enter your Employee Information. Fill in your Social Security Number, date of birth, and indicate if you are active, retired, or disabled.
- Next, provide your address details including city, state, and zip code. Specify your health plan name and type, and indicate if you have any other coverage.
- Proceed to Section B if the patient is not the employee. Enter their information including name, Social Security Number, relationship to the employee, and date of birth.
- If applicable, complete Section C for accident or occupational claim information by providing details about the incident.
- Finally, in Section D, ensure that both the member and patient (if applicable) sign and date the form to authorize processing.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2014 | 4.5 Satisfied (60 Votes) |
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Please refer to the MBF Benefits Booklet for complete details on the Superimposed Major Medical Plan. Download the MBF Benefits Booklet for more information (Read more