Download PDF Form - AFSPA - afspa 2026

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4.4 out of 5

113 votes

The document is a claim form for the Foreign Service Benefit Plan, requiring insured members to provide personal information, details about sickness or accidents, and other insurance coverage information. It emphasizes the need for complete and accurate responses to process claims and includes authorization for direct payment to physicians.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your full name and mailing address in the designated fields. Ensure all information is printed clearly.
Indicate your sex and provide your Subscriber ID. If this claim is for a dependent, include their given name and marital status.
Describe the sickness or accident suffered, including the date of the accident if applicable. Provide details on how and where the accident occurred.
Complete the section regarding other insurance coverage, ensuring you answer all questions accurately, especially if you have Medicare coverage.
Sign and date the form at the bottom, certifying that all information provided is complete and accurate.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (36 Votes)
2016	4.4 Satisfied (113 Votes)

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