Fidelity security life insurance company gap 2026

1. Click ‘Get Form’ to open the Fidelity Security Life Insurance Company Gap claim form in the editor.
2. Begin by completing the 'Statement of Insured' section. Fill in your name, policy number, employer name, and social security number. Ensure all details are accurate.
3. Provide your address, including city, state, and zip code. Next, enter the patient's name and relationship to you.
4. Detail the injury or sickness by describing it completely. Include the date of injury or onset of sickness and when you were first treated.
5. List the name and address of the physician who first treated this condition. Indicate whether the injury or sickness is work-related and if you will file for workers’ compensation.
6. Attach a copy of the Explanation of Benefits (EOB) from your Comprehensive Major Medical Plan along with an itemized bill that matches the EOB.
7. Review all information for accuracy before signing at the bottom of the form. Ensure you complete any required authorizations included with this form.

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